Hepatic resection techniques
- Steven A Curley, MD, FACS
Steven A Curley, MD, FACS
- Professor of Surgery
- Baylor College of Medicine
- Evan S Glazer, MD, PhD, MPH
Evan S Glazer, MD, PhD, MPH
- Assistant Professor of Surgery
- University of Tennessee Health Sciences Center
Hepatic (liver) resection is performed to manage benign or malignant pathologies of the liver, with the majority undertaken to manage primary or secondary liver tumors. Perioperative outcomes of hepatic resection have improved over time due to the development of surgical techniques that take better advantage of the segmental anatomy of the liver and improved control of bleeding, as well as advances in perioperative care. In addition, more of these procedures are being performed in tertiary centers by specially trained hepatobiliary surgeons who have a higher level of expertise, which is associated with better outcomes [1-3].
The techniques for hepatic resection are reviewed here. The indications for hepatic resection, perioperative care (including preoperative assessment of liver function to determine the required volume of remaining liver after resection), complications, and outcomes are reviewed separately. (See "Overview of hepatic resection".)
The liver is located in the right upper quadrant and weighs about 2 to 4 pounds (1.2 to 1.6 kg). Access to the liver for hepatic resection is achieved by mobilizing the liver from its various ligamentous attachments, including the coronary ligament, and left and right triangular ligaments (figure 1). The porta hepatis (figure 2) contains the structures that enter the liver, and the gastrohepatic ligament may contain accessory vessels that need to be controlled.
Segmental anatomy — The liver is divided into two lobar segments (right and left), and is further subdivided into eight segments (Couinaud) based upon its vascular supply or bile duct distribution (figure 3). Numerous anatomic classifications are available for liver resection. We use the description from the Brisbane 2000 standard (figure 4) [4,5].
●The eight main segments (figure 3) are based on portal vein anatomy including the caudate lobe (segment 1). A ninth segment is sometimes described as a portion of segment one, but to the right of the inferior vena cava. Although interesting, proximity to the inferior vena cava and the anatomic variability make formal recognition of the ninth segment of little consequence to hepatic resection.
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- SURGICAL ANATOMY
- Segmental anatomy
- Vascular supply
- GENERAL TECHNIQUES
- Staging laparoscopy and use of ultrasound
- Incision and exposure
- - Laparoscopic and robotic approach
- Dissection of the porta hepatis
- - Vascular control
- Division of the liver tissue and hemostasis
- Drainage and closure
- SPECIFIC RESECTIONS
- Wedge resection
- Segmental resection
- Left hemihepatectomy
- Right hemihepatectomy
- Anterior right sectorectomy
- Right extended hemihepatectomy
- Left extended hemihepatectomy
- SUMMARY AND RECOMMENDATIONS