Major hepatic resection: Right liver

Inflow and biliary control

The hilar plate is opened to expose the left hepatic duct and the confluence of the bile ducts. The cystic duct and the cystic artery are exposed, ligated, and divided ( Fig. 3.1 ), and the gallbladder is removed. The cystic duct is transfixed before being ligated, and a tie is left on the cystic duct for later retraction. Some surgeons now proceed to extrahepatic dissection of the right hepatic duct (see subsequent discussion), but this is not advisable. It is better to dissect the right hepatic artery and portal vein and to leave management of the right hepatic duct until later in the operation.

The right hepatic artery is dissected, ligated, and divided. We deliberately double-suture-ligate the proximal end and hold this after division for light traction to the left, which together with traction on the cystic duct stump is of assistance in exposing the portal vein ( Fig. 3.2 ).

The portal vein is approached laterally and posterior to the common hepatic duct. The main portal trunk is exposed, and the left branch is identified and preserved. Sometimes the right anterior and posterior sectoral branches of the portal vein arise individually (see Chapter 1 ), and these origins may be separated by as much as 2 cm (see Fig. 3.2 ).

A curved clamp is passed around the right portal vein under direct vision. Care should be taken not to damage the first posterior caudate branch of the right portal vein.

Application of a straight-bladed vascular clamp is a safe method of transecting the right portal vein (see Fig. 3.2 ). If the vein is ligated, it should be transfixed and double-ligated. The portal vein may also be divided using the Endo-GIA vascular stapler. If the right anterior and posterior sectoral branches arise independently (see Fig. 3.2 ), they require individual control. The hepatic bile duct or its major sectoral tributaries are usually secured in the pedicles (see the following section) farther laterally at the time of parenchymal dissection. However, deliberate dissection of the hepatic ducts must be carried out for tumors that approach the hilus of the liver.

The confluence of the bile ducts and the infrahepatic course of the left hepatic duct should be identified after lowering of the hilar plate (see Fig. 3.1 ). It may help to divide the liver tissue that occupies the lower limits of the umbilical fissure and bridges the gap between the quadrate lobe (segment IV) and segment III of the left liver. This maneuver opens the umbilical fissure and allows better exposure of the subhepatic and hilar area.

When the right hepatic duct is dissected, it should be transfixed, ligated, and divided (see Fig. 3.2 ). Difficulty might be encountered in passing an instrument around the right hepatic duct, in which case it may be divided under direct vision and subsequently oversewn with a 4-0 Vicryl suture (Vicryl; Ethicon, Edinburgh, UK) on an atraumatic needle. In many instances, the ducts draining the anterior and posterior right sectors are found entering the confluence separately, or the posterior sectoral duct may join the left hepatic duct (see Chapter 1 ). In such cases, both these major sectoral ducts should be individually identified and secured. It is again emphasized that extrahepatic dissection is not usually necessary for peripherally placed tumors. In such cases, pedicular control is adequate.

Control of portal pedicles

An important alternative to extrahepatic dissection of the hilar structures is the pedicle ligation technique using an intrahepatic approach. This technique allows the surgeon to dissect and clamp the required sheaths early in the operation and define the segment or segments to be removed.

The structures of the portal triad carry Glisson’s capsules with them as they penetrate the liver and are contained in a well-formed sheath within the parenchyma ( Fig. 3.3 ). The pedicular sheaths can be exposed after appropriate hepatotomies ( Fig. 3.4 ) and are tough enough to be dissected, encircled, and clamped ( Fig. 3.5 ).

It is important to ligate and divide the lowermost retrohepatic veins draining from the caudate process and lower part of the liver to the vena cava (see Fig. 3.4 ). Failure to do this may result in hemorrhage during passage of a finger or dissector (see Figs. 3.5 and 3.6 ) about the right portal pedicle. Care must be taken to respect the anatomy of the pedicles, in particular, the pedicle to the right posterior sector (see Figs. 3.5 and 3.6 ). When the right pedicle has been exposed (see Fig. 3.4 ) and trial clamping reveals the demarcation line along the Glissonian plane, the pedicle is divided using a vascular stapling device (see Fig. 3.4 ).