I read with interest the article on the anatomical resection of the left liver segments by Machado et al1 that appeared in the December issue of ARCHIVES.
Machado et al2 first published a paper about right portal pedicle isolation for right segmental liver resections and then this one about the same problem on the left liver. Like the authors, I too am interested in the extraglissonian approach to the liver portal pedicles and consider it very important and useful during right liver segmental resections (technique reported elsewhere).3 After this report, each time I have had to remove a tumor in the left liver, I have tried to isolate and clamp the segmental glissonian pedicle exactly in the same way as described by Machado et al. Unfortunately, the results have not been so enthusiastic. I realize that, except for the total control of the entire left portal pedicle, which is complete and reliable, the isolation of the segmental branches for segment II, III, and IV are not, resulting often incomplete. This is because of the fact that the segmental glissonian sheaths arising from the left pedicle and umbilical fissure are multiple and variable for each of these left segments. Frequently, some pedicles arise from the cranial part of these structures, deep in the left liver parenchyma,4 that can be reached and properly exposed at the end of liver transsection. Machado et al did a good job of describing the pedicles that are located superficially to the inferior face of the left liver, which are important and probably the main ones, but they are sometimes not the unique pedicle for that segment.