Right Hemihepatectomy by Suprahilar Intrahepatic Transection of the Right Hemipedicle using a Vascular Stapler

Summary

This video describes a right hemihepatectomy with intrahepatic transection of the right hemipedicle leaving the hepatoduodenal ligament completely untouched.

Abstract

Successful hepatic resection requires profound anatomical knowledge and delicate surgical technique. Hemihepatectomies are mostly performed after preparing the extrahepatic hilar structures within the hepatoduodenal ligament, even in benign tumours or liver metastasis.^1-5. Regional extrahepatic lymphadenectomy is an oncological standard in hilar cholangiocarcinoma, intrahepatic cholangio-cellular carcinoma and hepatocellular carcinoma, whereas lymph node metastases in the hepatic hilus in patients with liver metastasis are rarely occult. Major disadvantages of these procedures are the complex preparation of the hilus with the risk of injuring contralateral structures and the possibility of bleeding from portal vein side-branches or impaired perfusion of bile ducts. We developed a technique of right hemihepatectomy or resection of the left lateral segments with intrahepatic transection of the pedicle that leaves the hepatoduodenal ligament completely untouched. ⁶ However, if intraoperative visualization or palpation of the ligament is suspicious for tumor infiltration or lymph node metastasis, the hilus should be explored and a lymphadenectomy performed.

Protocol

Surgical Technique

1. The patient is bedded under standard operative room conditions in dorsal position and the whole abdomen is desinfected. Next, the patient is covered with sterile sheets.
2. After "reverse L-shaped" laparotomy the abdominal cavity is explored to exclude peritoneal carcinomatosis. Subsequently the ligamentum teres and the ligamentum falciforme are divided with ligatures and electrocautery.
3. Following exploration of the abdominal cavity careful bi-manual exploration of the hepatic ligament is performed to exclude extrahepatic lymph node metastasis. The extrahepatic hilar structures remain untouched if central tumor infilt....

Discussion

Hemihepatectomies are mostly performed after preparing the extrahepatic hilar structures within the hepatoduodenal ligament, even in benign tumours or liver metastasis.^1-5 In various centers, the parenchymal transection is performed under complete or selective hilar vascular occlusion. Major disadvantages of these procedures are the complex preparation of the hilus with the risk of injuring contralateral structures and the possibility of bleeding from portal vein side-branches or impaired perfusion of bile duc.......