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Operative Technique |

Anatomical Resection of Left Liver Segments

Marcel Autran C. Machado, MD; Paulo Herman, MD; Marcel C. C. Machado, MD
Arch Surg. 2004;139(12):1346-1349. doi:10.1001/archsurg.139.12.1346.
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Hypothesis  Anatomical resection of the left liver segments are rarely mentioned in the literature. We describe an anatomical access to the left liver segments’ pedicles without hilar dissection.

Design  Original surgical technique.

Patients and Methods  This technique was used in 26 consecutive resections involving left liver segments between July 2001 and December 2003. There were 15 men and 11 women with mean age of 57.1 years. Eleven patients had liver metastasis, 8 had primary liver cancer, 6 had benign lesions, and 1 had gallbladder cancer. The technique consists of small liver incisions according to anatomical landmarks such as the Arantius and round ligaments. In a systematized way, it was possible to reach every glissonian sheath of segments II, III, and IV.

Results  Liver resection was feasible using the proposed technique in every patient of this series, and the Pringle maneuver was not required in any patient. Intraoperative blood loss was minimal in all cases, and 23 patients did not require blood transfusion. There was no postoperative death.

Conclusions  This operative procedure allows easy, fast access for anatomical resection of the left liver segments. It is useful for performing controlled hepatectomies without clamping the main hepatic pedicle and may facilitate the recognition of all left liver segment sheaths, with excellent immediate results.

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liver

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Figures

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Figure 1.

Intraoperative photograph showing the landmarks for access of the left liver segments’ glissonian pedicles. Site A indicates the caudal stump of the Arantius ligament; B, the anterior incision in front of the hilum; C, the basis of the round ligament, right side; D, the basis of the round ligament, left side; E, midway between sites D and A. When a clamp is passed from site A to site B, it provides access to the left main sheath (containing the arterial, portal, and bile duct branches of segments II, III, and IV); from site A to site D, the left lobe sheath (segments II and III); from site E to site A, the segment II sheath; from site D to site E, the segment III sheath; and from site C to site B, the segment IV sheath.

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Figure 2.

Intraoperative access for the left main sheath (from site B to site A). Note the left hepatic vein is encircled (arrow).

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Figure 3.

Intraoperative view of the left liver segments approach. The left main sheath (LMS) as well as the segment III and IV sheaths are already encircled. The large clamp is encircling the segment II sheath.

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Figure 4.

Intraoperative view of segment III delineation.

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Figure 5.

Intraoperative view of raw surface of the liver after segment III resection.

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