Different Approaches to Liver Resection

Abstract

With better understanding of surgical anatomy, physiology and regeneration of the liver, and with improvements in technical developments in liver resection, alternative methods of approaches to liver resection evolved.

With better understanding of surgical anatomy, physiology and regeneration of the liver, and with improvements in technical developments in liver resection, alternative methods of approaches to liver resection evolved.

To make things simple, there are only five steps in liver resection before the resected specimen can be removed from the patient, and they are mobilisation of the liver by division of ligaments, interruption of the vasculo-biliary inflow, liver parenchymal transection, interruption of the venous outflow from the short hepatic veins and from the main hepatic veins. Obviously, adequate haemostasis is required before the abdomen is closed. The alternative approaches in liver resection involve the combination of these five steps in different orders. To complicate matters, the interruption of the vasculo-biliary inflow can be at a different site and level from the actual ligation and division of the vasculo-biliary inflow branches (e.g. Pringle’s manoeuvre at porta hepatis with intrahepatic division of the individual branches). Similarly, the outflow control can be at a site and level different from the division and ligation of the hepatic veins (e.g. extrahepatic control of the right hepatic vein with a vascular sling coupled with intrahepatic division and ligation of the vein). Furthermore, the alternative approaches also involve the division and ligation of the Glissonian pedicle with all its portal triads together, or the individual ligation and division of the hepatic arterial branch, the portal venous branch and the biliary branch separately.

15.1 Conventional Approach

This is the approach used by Lortart-Jacob and Robert for their first successful right hepatectomy reported in 1953.

15.1.1 Right Hepatectomy

This approach starts with mobilisation of the right liver by division of the falciform, coronary and right triangular ligaments. The right hepatic artery, the right portal vein and the right hepatic duct are ligated and divided extrahepatically (Fig. 15.1). The right liver is then dissected from the inferior vena cava. Short hepatic veins that drain from the right liver into the inferior vena cava are ligated and divided (Fig. 15.2a, b). The hepato-caval ligament is then divided between clamps and ligated. The right hepatic vein is dissected extrahepatically (see Sect. 13.6.1) divided and sutured (Fig. 15.2c). A line of demarcation is seen marking the devascularised right liver from the left liver (Fig. 15.3). Liver parenchymal transection can then be done, transecting the liver on the right border of the middle hepatic vein. Occasionally, the transection line of a right hepatectomy can be along the left border of the middle hepatic vein. Under this situation, care must be taken to preserve the segment 4 branch or the liver segment 4 would become congested (see Fig. 15.4).

Fig. 15.1

Dissection and slinging of the right hepatic artery (red sling), right portal vein (blue sling) and right hepatic duct (yellow sling)

Fig. 15.2

(a) Short hepatic veins and right hepatic vein from the right liver draining into the inferior vena cava. (b) Isolation of a short hepatic vein prior to ligation and division. (c) Isolation of the right hepatic vein before ligation and division

Fig. 15.3

Line of demarcation between right and left livers after the division of blood inflow and outflow to right liver

Fig. 15.4

Line of parenchymal transection for right hepatectomy

The segment 8 and segment 5 branches of the middle hepatic vein need to be ligated intrahepatically and divided.

Blood loss during parenchymal transection can be decreased by the use of Pringle’s manoeuvre and a low central venous pressure (see Chap. 12). Instead of using low central venous pressure, the trunk of the middle and the left hepatic veins can also be controlled with a clamp extrahepatically to prevent blood loss during parenchymal transection (selective hepatic vascular exclusion). The dissection of the trunk of the middle and left hepatic veins can be facilitated by the division of the ligamentum venosum near to its termination at the trunk of the hepatic veins (see Sect. 13.6.1). Once the ligamentum venosum is divided, the trunk can be dissected and looped with a vascular sling (see Sect. 6.10).

15.1.2 Left Hepatectomy

The procedure is similar to right hepatectomy with mobilisation of the left liver by division of the falciform and left triangular ligaments. Extrahepatic branch of the hepatic artery, left portal vein and left hepatic duct are divided and ligated extrahepatically. The trunk of the middle and left hepatic veins are isolated and slung. Parenchymal transection is along the plane demarcated by the ischaemic left liver along a plane on the left side of the middle hepatic vein. The left hepatic vein is ligated intrahepatically. Again, blood loss can be reduced by using Pringle’s manoeuvre plus either low central venous pressure or selective hepatic vascular exclusion by clamping the right hepatic vein as well. Please note that there is no short hepatic vein that drains from the left liver (segments 2, 3, 4) to the inferior vena cava.

15.1.3 Extended Right Hepatectomy (Right Trisectionectomy)

This is similar to carrying out right hepatectomy with the exception that the hepatic arterial, portal venous and bile ducts branches to segment 4 are also divided extrahepatically, and the right and middle hepatic veins are divided, leaving behind the portal triad supplying the left lateral section and the left hepatic vein.

15.1.4 Extended Left Hepatectomy (Left Trisectionectomy)

This is similar to carrying out left hepatectomy, with the exception that the hepatic arterial, portal venous and bile duct to the right posterior section, and the right hepatic vein are preserved, and the additional resection of the right anterior section. If the right inferior hepatic vein is large (see Sect. 7.4) this vein should be preserved, or the venous drainage to segment 6 can be affected.

15.2 Parenchymal Transection with Early Intrahepatic Control of Glissonian Sheath

15.2.1 Anterior Approach

This approach starts off with liver parenchymal transection of the liver. This procedure is commonly accompanied by temporary control of the portal triad using Pringle’s manoeuvre and low central venous pressure. Occasionally, liver parenchymal transection can proceed with minimal blood loss using some of the technical devices described in Chap. 14 without Pringle’s manoeuvre. Vascular inflow control can soon follow parenchymal transection by early intrahepatic approach to, and control of, the hepatic pedicle structures which are contained within the Glissonian sheath (Fig. 15.5). Further parenchymal transection and intrahepatic control of vessels follow until the parenchymal transection is complete. This is then followed by ligation and division of the hepatic venous branches, which include one or two of the major hepatic veins and the short hepatic veins (Fig. 15.6). Mobilisation of the falciform, coronary and triangular ligaments completes the resection and removal of the specimen.

Fig. 15.5

Right hepatectomy using the anterior approach

Fig. 15.6

Right hepatectomy using the anterior approach. Please note the completion of parenchymal transection before control of the venous structures (the right hepatic vein and the short hepatic veins) at the black of the liver

The beneficial effects of the anterior approach are there is less blood loss compared with the conventional approach, there is less chance of disseminating the tumour as a result of less manipulation on the tumour, there is less compromised blood flow to the remnant liver as a result of less kinking of the remnant liver during mobilisation, and there is less chance of rupturing the tumour when the tumour is large.

There are some limitations to the anterior approach. Some patients with a large tumour compressing a major hepatic vein can develop venous collaterals. In these patients, parenchymal transection without prior mobilisation of the liver is associated with massive bleeding from the venous collaterals. In such situation, after inflow clamping, the outflow should be resumed by mobilisation of the liver with an upper traction on the liver to facilitate venous flow into the inferior vena cava.

Nagasue in 1985 advocated the additional clamping of the hepatic vein draining the part of the liver being resected, claiming there to be less blood loss during resection than when the Pringle’s manoeuvre is used in isolation. However, this procedure requires early mobilisation of the liver, thus defeats the original purpose of the anterior approach: parenchymal transection to get early inflow occlusion, then further parenchymal transection, followed by outflow occlusion and mobilisation of the ligaments.

15.2.1.1 Belghiti’s Liver Hanging Technique

Belghiti proposed a liver hanging technique to facilitate the anterior approach.

The idea is to put a sling between the back of the liver and the front of the inferior vena cava at the ‘avascular tunnel’ (see Sect. 3.3) right at the back of the midplane of the liver (Fig. 15.7).

Fig. 15.7

Belghiti’s liver hanging technique transecting the liver at the mid plane

Intraoperative ultrasound is used to confirm the absence of tumour infiltration and abnormal short hepatic veins at the 10–11 O’clock position of the anterior surface of the retrohepatic inferior vena cava. After opening the anterior leaf of the coronary ligament and the anterior part of the right triangular ligament (to expose the anterior and left sides of the right hepatic vein), the fossa located between the right hepatic vein and the middle hepatic vein is dissected 3–4 cm downwards with a right-angled dissector (Fig. 15.7). For caudal retrohepatic dissection, the caudal edge of the caudate lobe is lifted from the inferior vena cava (Fig. 15.8a), and small short hepatic veins are divided and ligated up to the level of the inferior right hepatic vein. A long, tight, curved aortic clamp is inserted behind the caudate lobe just to the left side of the inferior right hepatic vein and is passed cranially along the anterior surface of the inferior vena cava between the 10 and 11 O’clock positions, identifying the position of the clamp tip by ultrasonography. By successfully opening and closing the clamp, the clamp is directed towards the previously dissected space between the right hepatic vein and the middle hepatic vein, while the clamp tip reaches suprahepatically (Fig. 15.8b). A 10 mm-wide soft silicon multitubular drain is seized with the clamp and pulled down through the retrohepatic space (Fig. 15.8c). When the right hepatectomy includes the middle hepatic vein, the tap is switched from the right to the left side of the middle hepatic vein; this allows safer dissection of the middle hepatic vein near the vena cava confluence. The caudate lobe is divided to place the tap near the right portal pedicle. The tap pulls up the liver, thus facilitated the anterior approach by pulling the liver tissue away from the inferior vena cava and protecting it from injury during transection (see Fig. 15.8d).

Fig. 15.8

Belghiti’s liver hanging technique. (a) Dissecting retroperitoneal tunnel. (b) Forceps came out of previously dissected plane at fossa between right hepatic vein and middle hepatic vein. (c) Silicon sling pulled liver up. (d) Diaphragmatic representation

The Belghiti’s hanging technique has a success rate of 80–92%. Adhesions between the liver and the inferior vena cava and direct tumour involvement are the main causes of failure. In 4–6% of cases, major bleeding happens because of torn short hepatic veins.

15.2.1.2 Chen’s Double Liver Hanging Technique Through the Retrohepatic Avascular Tunnel

This technique involves dissecting a tunnel on the right side of the inferior vena cava. As this is the medial part of the bare area, there is no vessel that runs in this space.

The procedure starts with dividing the posterior peritoneum, 2–3 cm wide, on the right side of the inferior vena cava, just inferior to the liver. The right adrenal gland is exposed and protected. The operator uses his right index finger, dissects the space from below upwards between the hepatic parenchyma and the anterior and superior edges of the right adrenal, then along the right side of the inferior vena cava. The right coronary ligament is opened suprahepatically on the right side of the inferior vena cava for 2–3 cm. The operator uses his left index finger to dissect the retrohepatic space from above downwards along the right side of the inferior vena cava. The retrohepatic tunnel is built when the fingers touch each other. A clamp is used to place two tapes around the liver for liver suspension. One tape is pulled to the right and the other to the left. Liver transection is done along a plane to the right of the middle hepatic vein as determined by intraoperative ultrasonography for right hepatectomy (Fig. 15.9). The liver double-hanging manoeuvre provides better exposure of the operative fields and easier manipulation during liver parenchymal transection. When the liver parenchymal transection reaches the right hepatic vein, the origin of the right hepatic vein from the inferior vena cava is dissected, doubly ligated and divided. Liver transection is then carried out along the right border of the inferior vena cava, dividing the caudate process and ligating and dividing the short hepatic veins.

Fig. 15.9

Chen’s double liver hanging manoeuvre

With this technique of right hepatectomy, the entire caudate lobe is preserved. While in Belghiti’s liver hanging techniques, parts of the paracaval portion and the caudate process are resected. Thus, this technique represents a right hepatectomy which is anatomically more correct.

The main advantage of this technique is the lack of bleeding in developing the tunnel as the tunnel goes through a true avascular space containing loose connective tissues only.

15.3 Glissonian Sheath Approach

This approach starts off with minimal parenchymal transection to expose the intrahepatic Glissonian sheaths followed by control of the portal triad within the sheath, then further parenchymal dissection till the liver is divided, then controlling the vascular outflow branches. Mobilisation of the liver can be done at the beginning of the operation or towards the end of the operation.

Launois described two approaches:

• 1. Launois Anterior Intrahepatic Approach

• 2. Launois and Jameison’s posterior intrahepatic approach to Glissonian Sheath (also see Sect. 4.3 Intrahepatic Transfissural Approach to the Conference of the Bile Duct)

Both the two approaches to the hepatic pedicles contained within the Glissonian sheath aid early vascular inflow control. The Launois and Jameison’s posterior intrahepatic approach can be accomplished in one of two ways. Firstly, the caudate process behind the gallbladder bed is divided vertically along the right side of the inferior vena cava. An extension of this incision is then made in the posterior aspect of the gallbladder bed (Incision 1 in Fig. 15.10). The surgeon’s forefinger and thumb of one hand are now placed within the liver substance, with the forefinger in the caudate process incision and thumb in the gallbladder fossa incision. At a depth of 10–20 mm, a sheath is usually encountered. It is encircled by a large curved clamp, and a tape is passed around it, this is often a sheath to segment 6. Dissection can now be undertaken further centrally or peripherally, depending on which sheath is being sought.

Fig. 15.10

Launios and Jameison’s posterior intrahepatic approach to the hepatic pedicles: Method 1: incision 1; Method 2: incisions 2, then 3

Secondly, they described a more central approach. First, an incision is made at the junction of the hilum with the liver substance of the caudate process, i.e. behind the hilum. This incision is approximately 20 mm in length (Incision 2 in Fig. 15.10). A second incision is then made in front of the hilum, and parallel to the first incision, extending from the gallbladder bed on the right to the umbilical fissure on the left (Incision 3 in Fig. 15.10). An index finger is passed into the incision behind the hilum and the undersurface of the sheath is kept above the finger until the superior part of the sheath is reached Fig. 15.11). A large curved clamp is then used to pass a tape around this region of the confluence. Traction on the tape tends to exteriorize both the right and left main sheaths (Fig. 15.12). Further dissection to the right exposes the anterior sectoral pedicle to segments 5 and 8, which passes upwards. The posterior sectoral pedicles to segments 6 and 7 run posterolateral. Dissection to the left exposes the sectoral branches to segment 4, and segments 2/3. Further dissection identifies the hepatic pedicle going into the individual liver segments making resection of individual or combination of sectors and individual or combination of segments possible.

Fig. 15.11

Launios and Jameison’s posterior intrahepatic approach: passing an index finger

Fig. 15.12

Using Launios and Jameison’s posterior intrahepatic approach, the right pedicle was isolated. A vascular stapler was applied. Note the demarcation separating the ischaemic right liver and the normally perfused left liver

15.3.1 Takasaki’s Glissonian Sheath Approach

Takasaki divided the liver into three almost equal parts: the right segment (equivalent to Couinaud segments 6, 7, or the right posterior sector); the middle segment (Couinaud segments 5, 8 or the right anterior sector); and the left segment (Couinaud segments 4, 3, 2 or the left medial and lateral sectors) (Figs. 15.13 and 15.14a, b).

Fig. 15.13

Takasaki’s liver ‘segments’

Fig. 15.14

(a) Dissecting of the liver parenchyma at the hepatic hilus exposed the 3 pedicles to Takasaki’s ‘segments’. (b) Operative photograph showing liver after resection of segments 4, 5, 8. Sling (a) around right hepatic vein. Sling (b) around left hepatic vein. Sling (c) around right posterior sectional pedicle (to segments 6, 7) and sling (d) around left lateral sectional pedicle (to segments 2, 3)

The Glissonian pedicles entering the liver for these three Takasaki ‘segments’ can be exposed by dissecting into the liver parenchyma at the hepatic hilum. Further dissection of these pedicles leads to the hepatic pedicles supplying the individual Couinaud segments. As a consequence, any Couinaud segment can be resected individually or in combination by ligation and division of the pedicle to the segment. Parenchymal transection can then follow the demarcation line of the ischaemic liver segment. The operation ends with the division of the outflow venous pedicle.

15.4 Segment-Based Liver Resection

Liver resection based on Couinaud liver segments is called segment-based liver resection. As each liver segment receives its own tributaries from the portal pedicles and drains independently into the tributaries of the hepatic veins, each segment is an independently functional unit and can be resected individually or in combination with other liver segments.

15.4.1 Advantages of Segment-Based Liver Resection

There are many theoretical advantages of segment-based liver resection:

• 1. The anatomical boundaries between the individual liver segments are not crossed by large branches of the portal pedicle (hepatic artery, portal vein and bile duct), these boundaries are relatively avascular planes that facilitate surgical resection and decrease intraoperative blood loss.

• 2. By avoiding damages to the portal pedicle, segment-based liver resection avoids leaving behind devitalized liver parenchyma in the liver remnant, thus avoiding the risk of infection and bile duct fistulation.

• 3. By predetermining the liver segments to be removed and by following the intrahepatic anatomy during parenchymal transection, an adequate resection margin can be guaranteed while at the same time preserving the largest amount of non-tumorous liver parenchyma.

• 4. There is a good oncological rationale for using segment-based liver resection because of liver tumour characteristics. Hepatocellular carcinoma usually grows and is confined to one liver segment in the early phase of the disease. Intrahepatic tumour spread originates from tumour invasion of the portal venous branches, giving rise first to satellite metastases within the same liver segment, followed by involvement of the corresponding part of the same sector, and ultimately a complete hemiliver or bilateral spread to the whole liver. Indeed vascular invasion and intrahepatic metastases are the risk factors that most strongly influence post-operative prognosis. Given that early satellite metastases lie in the same liver segment as the main tumour, segment-based liver resection should be used to give the best chance of oncological tumour clearance.

15.4.2 Techniques of Segment-Based Liver Resection

The application of the principles of segment-based liver resection has been facilitated by the development of modern imaging techniques. Preoperative ultrasonography, computed tomography or magnetic resonance imaging can accurately relate the location of the tumour in the liver segment(s). Thus, a preoperative planning can be made on the liver segment(s) to be resected (Sect. 10.2).

15.4.2.1 Surface Anatomy + IOUS

Intraoperative ultrasound (IOUS) together with the liver surface markings can help to define the exact location of the tumour (see Chap. 10), to determine the liver segment(s) to be resected and the amount of resection margin that can be achieved (Fig. 15.15).

Fig. 15.15

Resection of segments 4B based on surface anatomy. (a) Segment 4B between midplane of liver and falciform ligament. (b) After segment 4B resection (note segment 4A left behind)

After marking the planes of liver parenchymal transection on the surface of the liver, the liver is transected. The pedicles of the vessels and the bile ducts of the relevant liver segments are divided at the end of the parenchymal transection (Fig. 15.16). Pringle’s manoeuvre and a low central venous pressure are usually used. It is essential for surgeons to have a detailed knowledge of the intrahepatic anatomy and skill in IOUS before this technique can be used with good results.

Fig. 15.16

Resection of segments 4B. Slings around segments 6 pedicle (a); sling around pedicle 7 (b); and sling around anterior right sectional pedicle (c) (segments 5, 8). Forceps pointing to divided pedicles of segment 4

15.4.2.2 Preliminary Control of the Glissonian Pedicle of the Liver Segment to Be Removed

The Glissonian pedicles are approached at the hepatic hilus using either the Launois or the Takasaki’s technique. Lowering the liver plate helps to increase the extrahepatic length of these pedicles (see Chap. 4). By dissecting the right pedicle distally, the right anterior sectoral pedicle (segments 5, 8) and the right posterior sectoral pedicle (segments 6, 7) are found (Fig. 15.17). Similarly, by dissecting and tracing the left pedicle, the segment 4 pedicle and the segments 2/3 pedicle are found. Further dissection distally exposes the pedicles to the individual liver segments, but this dissection requires further parenchymal transection. Occlusion of the relevant pedicle by a bulldog clamp results in a change in colour of the liver segment. The arterial and portal pedicle are ligated and divided at the end of the parenchymal resection. This technique requires more tissue dissection and a longer operating time than the other techniques, and it is technically more difficult in patients with cirrhosis and portal hypertension.

Fig. 15.17

Dissection of right hepatic pedicle distally. (a) The right anterior sectional pedicle to segments 5, 8 (sling, a) and the right posterior sectional pedicle to segments 6, 7 (sling b). (b) Further dissection distally showed segment 5 pedicle (sling c). The right posterior sectional pedicle to segments 6, 7 at sling d. Pedicle to segment 8 divided for isolated segment 8 resection (arrow). Note sling e around right hepatic vein

An alternative technique is to isolate the pedicles to the segments or sectors and to clamp the pedicle with a vascular clamp to show the colour changes in the respective segment/sector (Fig. 15.18).

Fig. 15.18

Occlusion to hepatic pedicle showing colour changes in liver parenchyma. (a) To right hepatic pedicle. (b) To right posterior sectional pedicle supplying segments 6, 7. (c) Colour changes in segments 4, 5, 8. (d) Colour changes in segment 4

15.4.2.3 Ultrasound-Guided Puncture of Portal Vein Branch and Injection of Dye

The portal vein branch supplying the liver segment to be resected is punctured under ultrasound guidance. A few millilitres of methylene blue or Congo red is then infused into the portal branch. The dye stains the liver segment corresponding to the limits of the liver transection plane. Transection is then carried out. The technique requires great expertise in interventional ultrasound, and for this reason, has not gained wide acceptance.

15.4.2.4 Selective Portal Venous Occlusion Using a Balloon Catheter Through a Branch of the Superior Mesenteric Vein

This technique is carried out during open surgery using a bilateral subcostal incision with an upward midline extension. The liver is completely mobilised by the division of the liver ligaments. A 6 French balloon catheter is inserted into the portal vein via a branch of the superior mesenteric vein. The catheter is guided to the corresponding branch of the portal vein (either the right or the left), where the hepatocellular carcinoma is situated, with the surgeon’s hand in the porta hepatis. Once the tip of the catheter is in the intrahepatic portal venous system, further advancement of the catheter into the sectoral and segmental portal venous branches is done by rotating and advancing the catheter using the trial-and-error method. Guidance of the catheter tip into the desired portal venous branch is assisted with ultrasound and the surgeon’s hand in the porta hepatis.

When the balloon catheter is in the right position, the balloon is inflated with 3 mL of normal saline to occlude the venous branch, a few millilitres of methylene blue is injected through the catheters to delineate the liver segment to be resected. If the balloon catheter enters into a wrong pedicle supplying a liver segment that needs to be preserved, counter-staining with methylene blue helps to identify the segment to be resected because this segment remains unstained. The line of demarcation is marked on the liver surface with a diathermy device. The procedure is repeated if more than one liver segment needs to be delineated. The time required to get the catheter in the right position is around 10 min. The hepatic parenchyma is then transected along the line of demarcation. After haemostasis on the raw liver surface, the balloon catheter is deflated and removed, and the entry hole of the catheter into the liver segment is sutured. The branch of the superior mesenteric vein is ligated.

15.5 Non-Anatomical Liver Resection

Non-anatomical resection of centrally located tumour often results in inadequate tumour resection, especially at the deep margins. The operation is often associated with bleeding and results in a higher chance of biliary fistula and infection because devitalized liver segments are left behind.

Non-anatomical resection should only be carried out (1) when the tumour is situated at the border of several segments; (2) when the tumour is small and is situated peripherally at the edge of the liver. Under the latter situation, a wedge excision made in the shape of an arch or box is a simpler operation than a segment-based liver resection. Wedge excision should not be done in a V-shape because of the higher chance of the resection margin being involved by the tumour on histological study.

15.6 Caudate Lobe Resection

15.6.1 Classification of Caudate Lobectomy

The caudate lobe consists of three parts: the Spigelian lobe, the paracaval portion and the caudate process. In the majority of cases, the three parts receive different blood supply making partial caudate lobectomy a possibility (see Chap. 3). When resection of the caudate lobe is required for tumour clearance, the operation may be an isolated caudate lobe resection or a caudate lobe resection combined with a major hepatectomy, e.g. right hepatectomy. Thus, caudate lobectomy can be classified into four types: isolated complete caudate lobectomy, combined complete caudate lobectomy, isolated partial caudate lobectomy and combined partial caudate lobectomy (Fig. 15.19).

Fig. 15.19

Caudate lobectomy. (a) Isolated complete Caudate lobectomy. (b) Combined left hepatectomy and caudate lobectomy for a huge focal nodular hyperplasia. (c) Combined right hepatectomy and caudate lobectomy

15.6.2 Approaches to Caudate Lobectomy

There are five approaches.

15.6.2.1 Bilateral Approach

This is the most often used approach for isolated caudate lobectomy as it gives good exposure. The caudate lobe is approached from both the right and the left sides.

Technique: The liver is fully mobilised by the division of all its ligaments. The suprahepatic and the infrahepatic inferior vena cava is controlled by passing a tape around it so that total vascular outflow occlusion can be applied if necessary (see Chap. 13). The right adrenal vein is ligated, and the right adrenal gland is detached from the liver.

The peritoneal reflection between the Spigelian lobe and the inferior vena cava is incised. The right hepatic vein is controlled by a loop after the division of the hepato-caval ligament. The common trunk of the middle and left hepatic veins is controlled by a loop after the division of the ligamentum venosum. It is usual to use Pringle’s manoeuvre.

The caudate lobe is detached from the inferior vena cava by dissecting along the anterior surface of the retrohepatic inferior vena cava. The short hepatic veins are identified, ligated and divided (Fig. 15.20a). On the left side, the hepatogastric ligament (lesser omentum) is detached from the under surface of the liver (Fig. 15.20b), the fibrous hepato-caval ligament needs to be divided to free the Spigelian lobe from the inferior vena cava and the diaphragm. All short hepatic veins are ligated and divided, thus freeing the caudate lobe from the inferior vena cava (Fig. 15.20c).

Fig. 15.20

Bilateral approach caudate lobectomy. (a) Approach from right side to divide short hepatic veins to free the caudate lobe from the inferior vena cava. (b) Approach from left side, division of gastrohepatic ligament (lesser omentum). (c) Caudate lobe mobilised from left side after division of short hepatic veins. (d) Space left behind after removal of caudate lobe

On the right side, the caudate process is divided before the portal triad to the caudate process is isolated and divided. The branches to the paracaval portion of the caudate lobe from the right portal vein, right hepatic artery and right hepatic duct, and the branches to the Spiegelian lobe from the left portal vein, left hepatic artery and left hepatic duct are sought, ligated and divided.

By careful dissection, the liver is detached from the surrounding liver and the right, middle and left hepatic veins. There are two important landmarks for this dissection: the top of the caudate lobe which is located at the angle between the left hepatic vein and the inferior vena cava, and the point where the caudate process meets the right liver. An imaging line joining these two points can be considered as the caudate boundary for liver transection. Transection can start from either end or from both ends. Meticulous care should be paid not to injure the major hepatic veins or torrential bleeding can result, which can be difficult to control. After removal of the specimen, adequate haemostasis should be ensured.

15.6.2.2 Left-Sided Approach

Some small tumours <3 cm can be resected using a left-sided approach, especially if an isolated partial caudate lobectomy or a left hepatectomy is combined with a complete caudate lobectomy is carried out. The procedure is very similar to the bilateral approach with the exception that the dissection is mainly from the left side of the liver.

15.6.2.3 Right-Sided Approach

In a thin patient with a right hepatectomy combined with a complete caudate lobectomy, a right-sided approach can be done. Again the procedure is very similar to the bilateral approach with the exception that the dissection is mainly from the right side of the liver.

15.6.2.4 Anterior Approach

This is the approach for a caudate tumour larger than 4 cm, especially when the tumour is located in the paracaval portion or is in close contact with the major hepatic veins. This approach provides a better operative field by opening up the midplane of the liver widely so as to expose the major hepatic veins and the hilar plate to direct vision, thus facilitating dissection of the tumour from the main vessels.

Technique: The initial steps of the operation are similar to the bilateral approach.

After mobilising the liver by division of all the ligaments and having control of the suprahepatic and infrahepatic inferior vena cava, and the right and the trunk of the middle/left hepatic veins, the caudate lobe is freed from the retrohepatic inferior vena cava. Pringle’s manoeuvre is then applied. The liver is transected through the midplane, starting from the point between the roots of the right hepatic vein and the middle hepatic vein to the fossa of the gallbladder (which should have been removed). The transection is continued to the plane 1 cm from the tumour, as shown on intraoperative ultrasound (Fig. 15.21a). The transection then goes around a plane 0.5 cm from the tumour surface (Fig. 15.21b). When the transection reaches the hilar plate at the hilum, the caudate portal triads are isolated and divided (Fig. 15.21b, c).

Fig. 15.21

Anterior approach for caudate lobectomy. (a) Liver is transected at midplane down to 1 cm form tumour. (b) Dissection around tumour. Dissection of caudate portal traid from left hepatic pedicle. (c) Dissection of caudate portal traid from right posterior hepatic pedicle. (d) Space left after caudate lobectomy. IVC inferior vena cava. RHV right hepatic vein, LHV left hepatic vein

The caudate lobe together with the tumour is then separated from the major hepatic veins by careful parenchymal transection as described in the bilateral approach (Fig. 15.21d).

After removal of the specimen, all bleeding points and bile leaks are controlled individually.

15.6.2.5 Retrograde Caudate Lobectomy

All the technical approaches described above emphasise the early detachment of the caudate lobe from the retrohepatic inferior vena by division of the short hepatic veins. However, if the caudate lobe tumour is closely adherent to or has infiltrated the inferior vena cava or if it is too large in size to be turned from one side to the other, the retrograde caudate lobectomy has to be used instead. In this operation, the division and ligation of the short hepatic veins are left to the final stage of the operation.

Technique: Mobilisation of the liver by division of all the ligaments. The hepatoduodenal ligament, the suprahepatic and the infrahepatic inferior vena cava are looped for temporary occlusion if necessary.

The anterior transhepatic approach should be used, although occasionally the bilateral approach can be used. The liver is transected along the midplane down to 1 cm from the tumour (Fig. 15.22a). The hepatic veins are exposed under direct vision and meticulously dissected from the specimen. The caudate portal triads from the right/left hepatic arteries and right/left portal veins are ligated and divided. In combined right/left hepatectomy with caudate lobectomy, the right/left hepatic pedicle can be transected (Fig. 15.22b). The specimen is attached only to the inferior vena cava.

Fig. 15.22

Retrograde caudate lobectomy combined with right hepatectomy. (a) Liver transected at midplane down to 1 cm from tumour. (b) Division of right hepatic artery, portal vein and right duct. (c) Specimen isolated from inferior vena cava, and left attached to right hepatic vein. (d) Space left behind after resection

The distal and proximal parts of the caudate lobe are dissected from the inferior vena cava (Fig. 15.22c). Short hepatic veins, when encountered, are ligated and divided. If the tumour is attached to the inferior vena cava, part of the vein can be resected with the tumour (Fig. 15.22d). The inferior vena cava is then repaired with 40 prolene or reconstructed with an artificial graft.