Version May 2024
INTRODUCTION — 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 open 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 minimally invasive hepatic resection techniques are discussed elsewhere. (See "Minimally invasive liver resection (MILR)".)
SURGICAL ANATOMY — The liver is located in the right upper quadrant and weighs approximately 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 1, 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.
●Four sectors are based on hepatic vein anatomy (the caudate lobe is not included). These sectors are:
•Right posterior: Segments VI and VII.
•Right anterior: Segments V and VIII.
•Left medial: Segment IV.
•Left lateral: Segments II and III.
●Two sectors describe each hemi-liver (right, left).
•Left hemi-liver: Left medial and left lateral sectors (ie, segments II, III, and IV).
•Right hemi-liver: Right posterior and right anterior sectors (ie, segments V, VI, VII, and VIII).
•Excepting the caudate lobe, the right and left hemi-livers describe the liver in its entirety.
Vascular supply — The liver has a dual blood supply arising from the portal vein and the common hepatic artery (figure 5). The common hepatic artery is derived from the celiac axis and carries blood that is well oxygenated, supplying approximately 20 to 25 percent of the blood flow to the liver [6]. The remaining 75 to 80 percent of the blood flow to the liver is carried by the portal vein, which is a confluence of the splenic and superior mesenteric veins. Blood transported by the portal vein is less oxygenated but rich in nutrients absorbed from the small intestine.
The anatomy of the hepatic arterial system is highly variable, with variants identified in 55 to 79 percent of patients [7-9]. The most common variant is briefly described below. Other variations are shown in the figure (figure 6).
●A replaced right hepatic artery occurs in 11 to 21 percent of patients. It arises from the superior mesenteric artery and runs posterolateral to the common hepatic duct and portal vein (panel C in the figure) (figure 6). It can be identified by placing a finger through the foramen of Winslow and palpating the posterior aspect of the hepatoduodenal ligament.
●A replaced left hepatic artery occurs in 4 to 10 percent of patients. It originates from the left gastric artery and is easily identified as a prominent vessel running in the lesser omentum (gastrohepatic ligament) anterior to the caudate lobe (panel B in the figure) (figure 6).
The right and left hepatic artery and portal vein progressively divide to supply the segments of the liver and divide into smaller vessels, and ultimately capillaries, to supply the liver lobules, which are composed of hepatocytes. Blood collects in the hepatic sinusoids and drains into the central vein of the lobule, then into venules and segmental veins, and, ultimately, the blood from the liver drains into the vena cava via the hepatic veins (figure 5). The prevailing pattern of the hepatic veins in a study of 200 normal livers was a right hepatic vein (RHV) and a common trunk receiving the middle hepatic vein and left hepatic veins in 61 percent of the patients [10].
PREOPERATIVE EVALUATION — All patients requiring liver surgery should first undergo a formal and intensive evaluation as it pertains to perioperative and postoperative risks [11,12]. The details of this evaluation are discussed elsewhere. (See "Overview of hepatic resection", section on 'Preoperative evaluation and preparation'.)
GENERAL TECHNIQUES — Nearly all elective liver resections for tumor begin with evaluation for extrahepatic disease (ie, laparoscopy in some settings) and intraoperative liver ultrasound imaging to evaluate the potential for complete resection and to define the relevant anatomy. If resection is feasible, an upper abdominal incision (subcostal, bilateral subcostal [chevron], midline, or Makuuchi [inverted L]) is made and the liver is exposed. Cholecystectomy is usually performed followed by dissection of the porta hepatis to isolate and control the vascular and ductal structures. Thereafter, the liver tissue is divided to the extent that is mandated by the type of liver resection being undertaken and hemostasis achieved prior to abdominal closure. These general procedural steps are discussed in the sections that follow. Specific hepatic resections are discussed in detail below. (See 'Specific resections' below.)
Staging laparoscopy and use of ultrasound — Some patients will not be resectable even if preoperative imaging demonstrates focal disease. Thus, prior to undertaking hepatic resection, the abdomen should be explored to grossly examine the liver and look for extrahepatic metastatic disease that would preclude hepatic resection (eg, organ surfaces, peritoneum) [13-18]. If no obvious gross lesions are found, intraoperative ultrasound is routinely used to examine the liver parenchyma. Ultrasound can identify previously unseen lesions within the liver and is effective in detecting tumor thrombus that may indicate a need to extend the planned resection [16,19-21]. If the future liver remnant is significantly smaller than predicted preoperatively, vascular/biliary anatomy will not permit a safe or margin-negative resection, or a curative resection is unlikely (bilateral diffuse disease), the procedure should be terminated and the wounds closed. In one series of patients with hepatocellular carcinoma, 16 percent of 91 planned resections were aborted because of unresectable disease [13]. (See "Diagnostic staging laparoscopy for digestive system cancers", section on 'Liver cancer'.)
Incision and exposure — Depending on the patient's body habitus and site of lesion(s), we use either a standard laparotomy or a bilateral subcostal incision (figure 7) to obtain a generous exposure and access to most areas of the liver and major vessels. For posterior and large right liver tumors, we favor a Makuuchi (inverted L) incision. A superior midline extension from the subcostal incisions can be used for added exposure. When synchronous resection of a nonhepatic primary tumor (eg, colon cancer) and hepatic metastasis will be performed, an extended midline incision is often preferred. To reach the dome of the liver, for resecting large tumors or resecting tumors in segment VII or VIII, a right thoracoabdominal incision may be needed, although we rarely utilize this [22]. Technical aspects of abdominal incisions are discussed in detail elsewhere. (See "Incisions for open abdominal surgery".)
Once the incision has been made, abdominal exploration should be repeated. The liver should be inspected, palpated, and reimaged with ultrasound to confirm there are no contraindications to hepatic resection. Invasion of the porta hepatis or tumor on the posterior aspect of the liver is often a contraindication to standard resection.
The attachments of the liver to the diaphragm, retroperitoneum, and gastrohepatic ligament (coronary ligament, left and right triangular ligaments) are divided, as needed, to adequately expose the liver. We prefer to leave as many of the attachments undisturbed as possible, and if divided, we repair the attachments at the completion of the surgery (as able) to prevent postoperative hepatic torsion. (See "Overview of hepatic resection", section on 'Liver anatomy and physiology'.)
Laparoscopic and robotic approach — The role of minimally invasive liver surgery, while mildly controversial, continues to expand very quickly [23-26].
A laparoscopic approach is an alternative to open surgery [27]. For surgeons who have the appropriate experience with hepatic resection techniques and advanced laparoscopic skills, a laparoscopic or robotic approach (for benign or malignant disease) may be a reasonable option for small tumors if an adequate margin can be achieved without excessively prolonging operating time [28]. We find the robotic approach especially useful for small (<3 cm) lesions at the dome of the liver, while either the laparoscopic or the robotic approach is useful for peripheral lesions, left lateral sector lesions, and inferior right liver lesions. The use of a hand-assist port is a good option in patients undergoing laparoscopic resection who have a relatively large tumor that will need to be removed from a larger incision. A hand-assist port is also helpful while working with trainees.
A systematic review of observational studies found significant decreases in blood loss and length of stay with laparoscopic liver resection compared with open surgery [29]. For tumor resections, tumor clearance and recurrence rates did not appear to be different compared with open surgery [30-32]. Conversion from minimally invasive approaches to open approaches is generally associated with worse outcomes [33,34]. However, most studies were small, and adequately powered randomized trials are needed to prove equivalent oncologic outcomes.
Centers experienced in both hepatic resection and robotic surgery have performed robot-assisted hepatic resection. The overall utility and effectiveness of this approach, however, remain to be fully elucidated, as there are no randomized trials comparing outcomes of minimally invasive approaches (laparoscopic or robotic) with open approaches for liver resection [35,36].
Minimally invasive liver resection is discussed in another dedicated topic. (See "Minimally invasive liver resection (MILR)".)
Cholecystectomy — All major resections of the liver begin with cholecystectomy, which allows safe dissection and control of the structures of the porta hepatis and eliminates the gallbladder as a source of future problems. The gallbladder is usually removed after evaluation of the porta hepatis but before formal dissection. Once the cystic duct has been transected, a cholangiocatheter can be placed for subsequent cholangiograms, as needed. Technical aspects of open cholecystectomy and intraoperative cholangiography are discussed in detail elsewhere. (See "Open cholecystectomy".)
Dissection of the porta hepatis — Dissection of the porta hepatis is needed to a varying extent depending upon the type of hepatic resection chosen (figure 2). For major liver resections, it is nearly always performed. The portal vein, proper hepatic artery, and common hepatic duct should be identified and controlled prior to the ligation of any major vessels or hepatic parenchymal dissection. The objective of the dissection of the porta hepatis is proximal and distal control of each of the named structures, including the hepatic ducts, portal veins, and hepatic arteries. The location of the initial dissection in the porta hepatis is based upon the relative anatomy of the hepatic duct confluence/hilar plate, the vascular bifurcations, the confluence of the cystic duct remnant, and the common hepatic duct.
To perform dissection of the porta hepatis (figure 8):
●Prior to dissection, palpate the hepatoduodenal ligament to identify obvious aberrant (replaced right or left hepatic artery) or accessory structures (figure 6), which, if not appropriately identified and controlled, could lead to excessive bleeding from the transected surface of the liver. (See "Overview of hepatic resection", section on 'Liver anatomy and physiology'.)
●Begin the dissection at the cranial margin of the stomach and duodenum. Dissect, ligate, and divide perforating vessels from the hepatic arteries to the stomach.
●Identify the portal vein, which is between and slightly posterior to the common hepatic duct and the proper hepatic artery.
●Identify and dissect the common hepatic artery, gastroduodenal artery, proper hepatic artery, and right and left hepatic arteries circumferentially. During dissection of the right hepatic artery, avoid injury to the artery that supplies segment IV and the common hepatic duct. Such injury can lead to ischemia and late biliary stricture.
●Dissect the proper hepatic duct into the hilar plate to identify the right and left bile ducts. Take down the hilar plate in its entirety.
●Depending upon the type of resection, control these dissected structures (vessel loops, vascular clamps), or, for major resections, ligate the right or left of these (depending on the side of liver resection) within the porta hepatis.
•Divide and oversew the left or right bile duct with fine, nonabsorbable, monofilament suture.
•Clamp, divide, and suture-ligate the left or right hepatic artery.
•Ligate and divide the left or right portal vein and oversew its distal cut end (nonspecimen side). Alternatively, divide the portal vein with an endovascular linear cutting stapler.
●After ligation of the appropriate vascular structures, note the line of demarcation that develops on the surface of the liver and mark the planned dissection line with electrocautery. Intraoperative ultrasound can also be helpful in marking the limit of dissection.
Vascular control — To minimize blood loss during the course of dividing the liver tissue, particularly during resections that will not involve ligation of vessels of the porta hepatis, the vessels to the liver (hepatic artery, portal vein) can be dissected and individually controlled or occluded concurrently. Once the resection is completed, intraoperative duplex ultrasound should confirm normal flow in the remaining vascular structures, particularly if portal clamping was used.
Concurrent occlusion of the portal vascular structure (ie, Pringle maneuver) places a clamp across the hepatoduodenal ligament (figure 9) [37]. The earliest reports using the Pringle maneuver reported high mortality rates, but subsequently, randomized trials have shown significantly reduced blood loss and lower rates of transfusion [38-46]. The available literature suggests that the Pringle maneuver is uncommonly needed during elective hepatic resection due to improvements in technical skills and devices for dissection and control of bleeding [47] but may be appropriate in emergency circumstances, such as with traumatic hepatic injury. Rather than the Pringle maneuver, we prefer selective control of the vascular structures within the porta hepatis as described above.
We avoid continuous inflow occlusion (selective or concurrent). Selective inflow occlusion is associated with less hepatic injury compared with continuous occlusion [41,42]. During elective hepatic resection, one to two intermittent occlusions of short duration (less than 15 minutes) are usually all that are needed [38]. With selective, intermittent inflow occlusion, transfusion is needed in fewer than 7 percent of patients at high-volume centers [48]. A rest period of at least 10 minutes between occlusions is also important. During intermittent inflow occlusion, communication with the anesthesiologist regarding the patient's hemodynamic status and potential for reperfusion injury is important (if longer-duration occlusion is required).
Total hepatic isolation is another technique used for vascular control in which the hepatic artery, portal vein, and superior and inferior vena cava are occluded (figure 10) [49,50]. However, due to the difficulties in safely managing the retrohepatic vascular structures and associated complications, this technique is generally not used for elective hepatic resection [51]. We only use this technique if resection or controlled entrance into the inferior vena cava is a planned part of the liver procedure. The technique may be needed to prevent exsanguination when managing high-grade traumatic injuries to the liver. (See "Surgical techniques for managing hepatic injury", section on 'Severe injury'.)
A low central venous pressure (CVP; eg, 0 to 2 mmHg) may be an adjunctive maneuver to help minimize blood loss [52-55]. There are conflicting reports on the roles of low CVP anesthesia, partial hepatic isolation (infrahepatic inferior vena cava occlusion plus the Pringle maneuver), and total hepatic isolation. Among these, for elective hepatic resection, we favor low CVP plus the Pringle maneuver.
Division of the liver tissue and hemostasis — Liver resection, which is often technically challenging, involves the division of the liver tissue using standard surgical instruments or specialized devices for hemostasis, either anatomically, taking into account segmental anatomy, or nonanatomically (tissue division as needed). We suggest using the clamp-crush technique for liver parenchymal transection because it avoids dependance upon special equipment, is less expensive, and, in randomized trials, other methods have not demonstrated any added benefit with respect to decreasing transfusion requirements or perioperative morbidity [56-59]. Regardless of technique used, a thorough knowledge of the anatomy of the liver is essential. (See 'Surgical anatomy' above.)
For nonanatomic hepatic resection, division of the liver tissue and methods for hemostasis are similar to those discussed below for anatomic resection, but the dissection plane does not follow segmental anatomy.
Prior to parenchymal resection, the planned path of division must be demarcated. For major anatomic resection, the dissection plane will be demarcated as a result of ligation of the inflow structures of the segment or lobe. For less extensive resections, the dissection plane can be identified with the aid of intraoperative ultrasound and marked on the surface of the liver with a monopolar electrocautery (figure 11). Vertical mattress sutures can be placed into the liver tissue on either side of the dissection plane to compress the liver parenchyma and minimize bleeding associated with subsequent division of the liver tissue.
Alternatively, electromechanical tools may help in hepatic parenchymal dissection. Ultrasonic vibration (ie, "harmonic scalpel") can be used to dissect the liver capsule and first centimeter of superficial parenchyma over the planned surgical plane. Intraoperative ultrasound can easily confirm the resection plane and allows for subsequent division in a bloodless field. Another tool is microwave ablation to perform precoagulation along the planned parenchymal resection plane [60]. While this is not standard of care, the users of this technology suggest that it decreases blood loss during nonanatomic resection.
Electrosurgical devices are another good option for parenchymal dissection. Monopolar electrocautery can be used to divide the liver tissue between the mattress sutures placed at the liver capsule, but the predominant technique is the clamp-crush technique (figure 12), in which the liver tissue is gently broken apart using the surgeon's fingers after dividing the liver capsule. Larger vessels (>2 mm) and bile ducts are identified, clamped, and suture ligated, or, alternatively, they can be controlled using other electrosurgical devices. Electrosurgical devices include ultrasonic shears [61], the Cavitron Ultrasonic Surgical Aspirator (CUSA) [62-64], hydrojet, radiofrequency dissection sealer (RFDS) [57], and bipolar energy transfer systems [58]. These devices use various forms of energy to energize the tip of the device to divide and seal structures, including vessels, up to 5 to 6 mm (depending upon the device) [17,65]. We are most experienced with bipolar devices for vessel sealing when not performing the crush-clamp technique. The basic principles of the various electrosurgical devices are described elsewhere. (See "Overview of electrosurgery" and "Instruments and devices used in laparoscopic surgery", section on 'Devices for hemostasis'.)
Vascular staplers may be appropriate for dividing larger vessels [66,67]. Articulating vascular staplers can also be used to divide the liver tissue and provide hemostasis, often in combination with electrocautery or ultrasonic dissection [68]. In a small randomized trial, parenchymal transection with staplers resulted in both time-saving and blood loss reduction compared with LigaSure parenchymal transection [69]. For vascular stapler dissection, a combination of clamp-crush and electrocautery prepares the hepatic surface for stapler placement. Once aligned, a series of firings divides and ligates the remaining structures (vessels, ducts) as the liver parenchyma is traversed. Laparoscopic stapling devices can also be used for dividing larger vessels in the liver tissue; however, some larger vessels may need to be ligated by hand (suture ligated, doubly ligated). Articulating staplers provide more precise placement than standard staplers.
A systematic review evaluated seven trials comparing the clamp-crush technique with different methods of liver dissection and hemostasis [56]. There were no significant differences in markers of liver parenchymal injury or liver dysfunction, length of intensive care or hospital stay, morbidity, or mortality between the various methods. Transfusion requirements were lower using the clamp-crush technique compared with CUSA and hydrojet. There was no difference in the transfusion requirements of clamp-crush technique and sharp dissection. The clamp-crush technique was quicker than CUSA, hydrojet, and RFDS. The clamp-crush technique was two to six times less expensive than the other methods depending upon the number of surgeries performed each year. Other studies have found that certain devices may decrease operating times, but there were no significant differences in short-term or long-term outcomes compared with the clamp-crush technique [57,58].
Once the resection is completed, the hepatic surface should be thoroughly inspected. Discrete vessels on the liver surface can be ligated or clipped. Nonspecific bleeding from the raw liver surface can be controlled using the argon beam coagulator or using topical hemostatic agents (table 1). (See "Overview of topical hemostatic agents and tissue adhesives".)
Overall, the two most significant factors in the division of the liver tissue are (1) tissue quality of the liver (adiposity or fibrosis) and (2) tools and techniques most familiar to the surgical team. We approach each patient's liver from a "use what works" approach, so it remains important that liver surgeons are familiar with multiple parenchymal dividing options.
Residual bile leaks can be addressed using electrocautery, surgical clips, or additional sutures. If needed, persistent bile leaks can be evaluated using cholangiography, which can be performed by injecting gastrointestinal contrast into the cystic duct stump if the gallbladder has been removed, or into the common bile duct while temporarily occluding the distal common bile duct [70-72].
Drainage and closure — After the resection is completed and hemostasis from the raw surface of the liver is achieved, the abdominal wall fascia and skin are closed in the standard fashion. We usually place a falciform ligament flap or an omental pedicle flap on the raw surface of the remnant liver. (See "Principles of abdominal wall closure".)
Because there is minimal evidence of any benefit, drains do not need to be routinely placed [73-75]. However, in some cases, a closed-suction drain may be necessary, especially if there is concern for oozing or biliary leak. If a drain is placed, we typically place a supra-, infra-, or retrohepatic drain that is not directly in contact with the raw surface of the liver.
Although the rate of pleural effusion following hepatic resection is at least 10 percent, a chest tube should not be placed unless the diaphragm has been violated [76]. Once the diaphragmatic defect is repaired, the chest tube should be placed in the standard fashion and directed posteriorly. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children".)
SPECIFIC RESECTIONS — The types of resection (figure 4) include wedge resection, segmental resection (segmentectomy, sectorectomy), hepatectomy (right or left), and extended hepatectomy (right or left). Resection of the caudate lobe is described as a separate procedure from all other liver resections. Each of these, except wedge resection, is based upon the segmental anatomy of the liver (figure 3). (See 'Segmental anatomy' above.)
The type of hepatic resection chosen depends upon the location of the lesion(s), the ability to provide an adequate liver remnant, and, for malignant disease, a tumor-negative margin, which are generally determined during preoperative imaging. (See "Overview of hepatic resection", section on 'Preoperative imaging' and "Overview of hepatic resection", section on 'Resection margins'.)
A tumor-negative margin may be more likely achieved using an anatomic rather than nonanatomic approach; however, nonanatomic resection may be needed to manage malignancy if the expected residual volume of the liver would be insufficient following an anatomic resection. If high-quality imaging has effectively ruled out malignancy, nonanatomic resection is also acceptable. (See "Overview of hepatic resection", section on 'Preoperative imaging' and "Overview of hepatic resection", section on 'Type and extent of resection'.)
Wedge resection — Benign lesions at the periphery of the liver can be resected nonanatomically with a simple wedge resection (figure 4). Small malignant lesions at the periphery can also be resected in this manner. A laparoscopic approach to wedge resection may be possible, provided an adequate margin of parenchyma surrounding the lesion can be resected [28]. (See 'Laparoscopic and robotic approach' above.)
To perform a wedge resection:
●Mark the limit of the planned resection on the surface of the liver in the shape of a large "V" using electrocautery, with the open part of the "V" located on the free edge of the liver. Alternatively, if the lesion is located near the dome of the liver, mark a circle around the lesion.
●Divide the liver surface and parenchymal tissue using one of the methods discussed above. Hemostasis of the raw surface of the liver can be achieved using a topical hemostatic agent or electrosurgical device. Care must be taken to avoid injuring or ligating a named structure (ie, a segmental vessel or duct). If this occurs, it will require resection of that segment. (See 'Division of the liver tissue and hemostasis' above.)
Segmental resection — Segmental resection (partial lobectomy) refers to the anatomic resection of one or more segments of the liver (figure 4). Multiple segments are referred to as sectors, and their removal is referred to as a sector resection or sectorectomy. The main use of segmental resection is removal of an isolated lesion located at the center of a segment where anatomic resection has a high probability of obtaining a tumor-free margin. (See 'Surgical anatomy' above.)
To perform segmental resection:
●Perform laparoscopy and ultrasound to confirm resectability of the lesion. (See 'Staging laparoscopy and use of ultrasound' above.)
●Perform cholecystectomy. (See 'Cholecystectomy' above.)
●Dissect and control the vascular structures of the porta hepatis. (See 'Dissection of the porta hepatis' above.)
●Mark the transection plane on the surface of the liver using electrocautery. The transection plane is determined using a combination of the location of the lesion, important vascular/biliary structures, and anatomic relationships within the remaining/future liver remnant. This is achieved using ultrasound and vascular demarcation, if portal structures are ligated. For example, ligation of a hepatic artery branch and portal venous branch typically results in significant discoloration (ischemic changes) to that portion of the liver. Assuming the lesion of interest is confirmed present within the zone of ischemic tissue and no critical structure exists in the plane of demarcation as seen with ultrasound, then those demarcation lines are used as transection planes.
●Divide the parenchyma using the techniques described above, until the segmental blood supply is reached. (See 'Division of the liver tissue and hemostasis' above.)
●Temporarily occlude (eg, bulldog, vascular loop) the segmental vessels prior to division, and confirm using ultrasound that blood flow to the remaining segments of the lobe is adequate.
●Perform cholangiography to confirm adequate biliary drainage of the remaining segments.
●Once adequate perfusion and biliary drainage to the remainder of the liver is confirmed, divide the segmental vessels. We use a linear stapling device to divide the segmental hepatic artery and portal vein and the associated hepatic duct.
●Continue dividing the parenchyma until the segmental hepatic vein is identified. Divide the vein and suture ligate or staple across it.
●Using a topical hemostatic agent or electrosurgical device, achieve hemostasis of the raw surface of the liver.
Left hemihepatectomy — Left hemihepatectomy removes the entire left hemi-liver (figure 4).
To perform left hemihepatectomy:
●Perform laparoscopy and ultrasound to confirm resectability of the lesion. (See 'Staging laparoscopy and use of ultrasound' above.)
●Perform cholecystectomy. (See 'Cholecystectomy' above.)
●Dissect and control the structures of the porta hepatis. (See 'Dissection of the porta hepatis' above.)
●Ligate the left portal vein and left hepatic artery demarcating the left liver from the right liver.
●Start the parenchymal resection from the free edge of the liver. Using intraoperative ultrasound, divide the liver parenchyma following the middle hepatic vein as a guide. Preserve the tributaries draining the right lobe of the liver while ligating those draining segment IV (figure 13). Divide the parenchyma using the techniques described above. (See 'Division of the liver tissue and hemostasis' above.)
●Ligate and divide the left hepatic duct as it is encountered.
●Once the confluence of the middle and left hepatic veins is identified and controlled, suture-ligate or staple the left hepatic vein. If the caudate lobe is to be removed, continue the dissection to the inferior vena cava, and ligate and divide the hepatic veins draining the caudate lobe.
●Continue the parenchymal dissection to the posterior edge of the liver to free and deliver the left hemi-liver from the field.
●Using topical hemostatic agents or an electrosurgical device, achieve hemostasis of the raw surface of the liver. (See 'Division of the liver tissue and hemostasis' above.)
●Once hemostasis is achieved and any bile leaks are controlled, reattach the divided ligamentous attachments anchoring the remaining liver to the abdominal wall.
Right hemihepatectomy — Right hepatectomy removes the entire right hemi-liver (figure 4).
To perform right hemihepatectomy:
●Perform laparoscopy and ultrasound to confirm resectability of the lesion. (See 'Staging laparoscopy and use of ultrasound' above.)
●Divide the ligaments attaching the right liver to the diaphragm. During right hepatectomy, the left liver is at risk for atypical torsion. Keep the left liver in line with its vascular pedicle to avoid torsion and compression that can lead to ischemic injury to the liver remnant.
●Perform cholecystectomy. (See 'Cholecystectomy' above.)
●Dissect and control the structures of the porta hepatis. (See 'Dissection of the porta hepatis' above.)
●Ligate the right portal vein and right hepatic artery demarcating the right liver from the left liver.
●Start the parenchymal resection from the free edge of the liver, and continue along the inferior surface of the liver (figure 14). Using intraoperative ultrasound, divide the liver parenchyma following the middle hepatic vein as a guide (figure 15). Preserve the tributaries draining segment IV while ligating those draining the right lobe of the liver. Divide the parenchyma using the techniques described above. (See 'Division of the liver tissue and hemostasis' above.)
●Ligate and divide the right hepatic duct as it is encountered.
●Divide and ligate any small tributaries draining directly into the inferior vena cava.
●Use a vascular stapler to divide the right inferior vena caval ligament since liver and vascular tissue is often contained within it (figure 16).
●Dissect the right hepatic vein circumferentially and suture-ligate, oversew, or divide with a stapler.
●Continue the parenchymal dissection to the dome of the liver to free and deliver the right hemi-liver from the field.
●Using topical hemostatic agents or an electrosurgical device, achieve hemostasis of the raw surface of the liver. (See 'Division of the liver tissue and hemostasis' above.)
●Once hemostasis is obtained and any bile leaks are controlled, reattach the divided ligamentous attachments anchoring the remaining liver to the abdominal wall.
Anterior right sectorectomy — Anterior right sectorectomy (figure 4) removes segment V and VIII (figure 3).
To perform anterior right sectorectomy:
●Perform laparoscopy and ultrasound to confirm resectability of the lesion. (See 'Staging laparoscopy and use of ultrasound' above.)
●Maintain the ligamentous attachments of the liver during parenchymal resection, which differs from most other resections.
●Perform cholecystectomy. (See 'Cholecystectomy' above.)
●Dissect and control the structures of the porta hepatis. (See 'Dissection of the porta hepatis' above.)
●Divide the right anterior sector pedicle containing the hepatic duct, artery, and portal vein supplying segments V and VIII (right hepatic vein remains intact).
●Start the parenchymal resection from the anterior surface of the liver dissecting posteriorly toward the caudate lobe. Using intraoperative ultrasound, divide the liver parenchyma, following the middle hepatic vein as a guide (figure 3). The dissection proceeds on the right side of the middle hepatic vein. The caudate lobe may or may not be included in the resection. Divide the parenchyma using the techniques described above. (See 'Division of the liver tissue and hemostasis' above.)
●Ligate and divide the multiple small hepatic veins followed by division of the right hepatic vein with a stapler.
●Divide the right inferior vena caval ligament and triangular ligament. Use a vascular stapler to divide the inferior vena caval ligament since liver tissue is often contained within it (figure 16).
●Free and deliver the sector from the field.
●Using topical hemostatic agents or an electrosurgical device, achieve hemostasis of the raw surface of the liver. (See 'Division of the liver tissue and hemostasis' above.)
Right extended hemihepatectomy — Right extended hemihepatectomy (formerly termed right trisegmentectomy) (figure 4) involves the resection of the right lobe of the liver (segments V, VI, VII, VIII) and caudate lobe (segment I) along with segment IV (figure 3). Segment II and segment III remain. Leaving segment I is an option in some patients, but it can be technically challenging.
A common indication for extended right hepatectomy is a right hepatic lesion, such as an intrahepatic cholangiocarcinoma or colorectal cancer metastasis, extending into the medial segment of the left liver (segment IV). Due to the extent of the resection, it is important to evaluate the volume of the future liver remnant, which must be adequate to allow a reasonable probability of recovery. (See "Overview of hepatic resection", section on 'Preoperative imaging'.)
To perform right extended hemihepatectomy:
●Perform laparoscopy and ultrasound to confirm resectability of the lesion. (See 'Staging laparoscopy and use of ultrasound' above.)
●Divide the falciform, both triangular, and the right coronary ligaments. During extended right hepatectomy, as with right hepatectomy, the left liver is at risk for atypical torsion. Keep the left liver in line with its vascular pedicles to avoid torsion and compression that can lead to ischemic injury to the liver remnant.
●Perform cholecystectomy. (See 'Cholecystectomy' above.)
●Dissect and control the structures of the porta hepatis. (See 'Dissection of the porta hepatis' above.)
●Ligate the right portal vein and right hepatic artery demarcating the right liver from the left liver. The vascular line of demarcation will not be accurate, since the artery to the left medial sector (segment IV, segment I) remains intact.
●Identify a resection plane using intraoperative duplex that will permit resection of the lesion with adequate margins and leave the left lateral sector hepatic arterial, portal venous, biliary ducts, and hepatic venous structures intact.
●Start the parenchymal dissection anteriorly and continue between segments II and III and segments IV and VIII (figure 3). Use intraoperative ultrasound/duplex to identify the left hepatic vein branches, taking care to ligate only those directly draining the right liver. Ligate the hepatic arterial branches to and portal venous tributaries from segment IV as they are encountered. (See 'Division of the liver tissue and hemostasis' above.)
●Ligate and divide the middle and right hepatic veins with a vascular stapler. After division of the right hepatic artery, right portal vein, and right/middle hepatic vein, focus attention on the right hepatic duct and the arterial supply to the medial segment of the left liver.
●Continue the parenchymal dissection with sequential ligation of structures (often branches of branches) as they are encountered, leaving critical structures supplying the left lateral sector in place. The liver remnant requires adequate inflow and outflow, which often necessitates skeletonization of the branches of named structures. Divide the parenchyma using the techniques described above to free and deliver the specimen from the field. (See 'Division of the liver tissue and hemostasis' above.)
●Hemostasis of the raw surface of the liver can be achieved using topical hemostatic agents, suture ligation, or an electrosurgical device. Suture ligation of visible structures (ducts and vessels) is preferred, but these are often retracted if not adequately ligated during initial dissection. (See 'Division of the liver tissue and hemostasis' above.)
Left extended hemihepatectomy — Extended left hemihepatectomy (left trisegmentectomy) (figure 4) is similar to extended right hepatectomy; a left extended hepatectomy is useful for patients who have left-sided lesions that encroach on segments V and VIII (figure 3). This procedure should only be attempted if there will be an adequate liver remnant.
To perform left hemihepatectomy:
●Perform laparoscopy and ultrasound to confirm resectability of the lesion. (See 'Staging laparoscopy and use of ultrasound' above.)
●Perform cholecystectomy. (See 'Cholecystectomy' above.)
●Dissect and control the structures of the porta hepatis. (See 'Dissection of the porta hepatis' above.)
●Ligate the left portal vein and left hepatic artery demarcating the left liver from the right liver.
●Start the parenchymal resection from the free edge of the liver. Using intraoperative ultrasound, divide the liver parenchyma, following the middle hepatic vein as a guide. The resection plane stays to the right side of the middle hepatic vein. Preserve the tributaries draining the right lobe of the liver while ligating those draining segment IV. Divide the parenchyma using the techniques described above. (See 'Division of the liver tissue and hemostasis' above.)
●Identify the anterior branch of the right portal vein, hepatic artery, and biliary branches with ultrasound. Temporarily occlude the right anterior portal vein and right anterior hepatic artery with an intraparenchymal clamp and confirm with duplex that the blood supply to the liver remnant (right posterior sector) is adequate.
●Ligate and divide the left hepatic duct as it is encountered.
●Ligate and divide the vessels supplying segments V and VIII (right anterior sector). We often perform this with an articulating stapler (vascular load) in an intraparenchymal fashion (ultrasound guided, if needed). An alternative approach is to demarcate the plane of resection while clamping the right anterior structures (as described above) and beginning the parenchymal transection with the clamp in place until better visualizing is achieved. At that point, a stapler is used to ligate the right anterior structures under direct visualization.
●Continue the resection at the vascular demarcation line. On the inferior surface, control the middle and left hepatic veins and divide using a stapler. Some mobilization, such as dividing the diaphragmatic ligaments, will be needed. Continue the dissection along the left side of the right hepatic vein to the posterior edge of the liver to free and deliver the specimen from the field. (See 'Division of the liver tissue and hemostasis' above.)
●Once hemostasis is achieved and any bile leaks are controlled, the remaining liver should be anchored to the abdominal wall by reattaching any of the divided ligamentous attachments.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Liver resection and ablation".)
SUMMARY AND RECOMMENDATIONS
●Indications for hepatic resection – Hepatic (liver) resection is used to manage many types of liver pathology, benign and malignant. Malignant tumor within the liver (primary or secondary) is the most common indication for hepatic resection. Benign liver conditions that require hepatic resection are usually symptomatic and can be congenital or acquired. Hepatic trauma is most commonly managed conservatively but on occasion will require hepatic resection to definitively manage hemorrhage. (See 'Introduction' above and "Overview of hepatic resection", section on 'Indications for hepatic resection'.)
●Staging laparoscopy – For some patients undergoing hepatic resection for malignancy, we perform a staging laparoscopy and intraoperative laparoscopic ultrasound to confirm that resection is possible rather than proceeding directly to open laparotomy. The procedure will need to be terminated without hepatic resection for laparoscopic findings indicating that a curative resection is unlikely, the future liver remnant will be inadequate, or vascular/biliary anatomy will not permit a safe or margin-negative resection. (See 'Staging laparoscopy and use of ultrasound' above and "Diagnostic staging laparoscopy for digestive system cancers", section on 'Liver cancer'.)
●Vascular control – For elective hepatic resection that does not involve ligation of the right or left vascular structures in the porta hepatis, we control the hepatic arteries and portal veins in the porta hepatis individually (vessel loops, clamps) rather than concurrently (ie, Pringle maneuver). The Pringle maneuver may be more appropriate under emergency circumstances, such as with liver trauma. When vascular occlusion is needed, we suggest intermittent occlusion rather than continuous inflow occlusion (Grade 2C). (See 'Vascular control' above.)
●Types of resection – Hepatic resection can be performed by dividing the liver tissue nonanatomically or anatomically along planes based upon segmental anatomy (figure 3). The type of resection depends upon the location of the lesion(s) and, for malignant disease, the ability to provide a tumor-negative margin, which may be more likely achieved using an anatomic rather than nonanatomic approach. However, nonanatomic resection may be needed to manage malignancy if the expected residual volume of the liver would be insufficient following an anatomic resection. If high-quality imaging has effectively ruled out malignancy, nonanatomic resection is also acceptable. The types of hepatic resection (figure 4) include the following (see "Overview of hepatic resection", section on 'Type and extent of resection' and 'Specific resections' above):
•Wedge resection removes a "V"-shaped portion at the margin of the liver.
•Segmental resection (segmentectomy, sectorectomy) is the resection of one or more segments of the liver.
•Hemihepatectomy removes one of the lobes of the liver, right or left.
•Extended hemihepatectomy (formerly trisegmentectomy) removes one of the lobes of the liver (right or left) plus at least a portion of an additional segment(s).
●Parenchymal division – No significant differences in the various techniques with respect to transfusion rates or other clinically important outcomes have been demonstrated, but the clamp-crush technique, which does not require specialized equipment, is significantly less expensive and, with experience, may be quicker to perform than electrosurgical approaches. Surgical staplers are a commonly used alternative to the clamp-crush method for liver parenchymal division. Liver surgeons should be familiar with multiple parenchymal dividing options. (See 'Division of the liver tissue and hemostasis' above.)
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