ANATOMIC VARIABILITY IS THE RULE RATHER THAN THE EXCEPTION IN LIVER SURGERY

1. SURGICAL ANATOMY OF LIVER
MODERATOR : Dr PRADEEP JOSHI

2. Anatomic variability is the rule rather than the
exception in liver surgery
• Embryology
• Peritoneal attachments
• Classifications
• Caudate lobe
• Bile duct anatomy
• Hepatic artery anatomy
• Hepatic venous anatomy
• Portal vein anatomy
• Plate system

3. Embryology
• Biliary system and liver originate from
the embryonic foregut as a diverticulum
at four weeks
• Liver diverticulum initially separates into
a caudal and cranial portion. The
caudal portion gives rise to the cystic
duct and gallbladder and the cranial
portion gives rise to the intrahepatic and
hilar bile ducts.
• The cranial endodermal diverticulum
extends into the septum transversum
mesenchyme promoting formation of
endothelium and blood cells. The
extrahepatic biliary system is initially
occluded with epithelial cells but later it
canalizes as cells degenerate

5. Segmental anatomy
• 8 functionally indepedent segments with its own
vascular inflow, outflow and biliary drainage
• Middle hepatic vein divides the liver into right
and left hemiliver. This plane runs from the
inferior vena cava to the gallbladder fossa.
• Right hepatic vein divides the right lobe into
anterior and posterior segments.
• Left hepatic vein divides the left lobe into a
medial and lateral part.
• Portal vein divides the liver into upper and lower
segments

6. Cantlie’s line
• Couinaud divided the liver into a functional
left and right liver (in French 'gauche et
droite foie') by a main portal scissurae
containing the middle hepatic vein. This is
known as Cantlie's line.
• Cantlie's line runs from the middle of the
gallbladder fossa anteriorly to the inferior
vena cava posteriorly

7. Peritoneal attachments of Liver
• Include falciform ligament, the left triangular ligament , and
the coronary ligament with the right triangular ligament
•There are no right and left coronary ligaments, only the left
triangular and the complex of coronary and rt triangular
ligaments
• They represent the remnants of liver’s development in the
septum transversum
•Falciform ligament carries the obliterated left umbilical vein
& the round ligament. The coronary ligament carries the
hepatic veins and the retroperitoneal IVC . The left triangular
ligament may also contain large blood vessels
•Falciform ligament – main blood supply arises from left
inferior phrenic and middle hepatic arteries. Veins converge
into 2 branches and ultimately drain in to left inferior phrenic
vein
7

8. Peritoneal attachments of
Liver
•Liver is suspended mostly by
the fibrous attachments in the
bare area and by the attachment
of the hepatic veins to the IVC
•Double layer of parietal
peritoneum – continues to form
falciform ligament sagitally–
surrounds all except bare area
•left layer of falciform lig forms
the ant layer of left triangular lig
•Coronary lig has sup and inf
layers rather than anterior and
posterior layers which are united
laterally at angular extensions
forming the left and right
triangular ligaments. On the right
the two layers are widely
separated and they are named
coronary ligaments.
8

9. Bismuth's classification
• Similar to the Couinaud classification, although there are small differences.
It is popular in the United States, while Couinaud's classification is more
popular in Asia and Europe.
• According to Bismuth 3 hepatic veins divide the liver into 4 sectors, further
divided into segments. These sectors are termed portal sectors as each is
supplied by a portal pedicle in the centre.
• The separation line between sectors contain a hepatic vein. The hepatic
veins and portal pedicles are intertwined.
• The left portal scissura divides the left liver into two sectors: anterior and
posterior. Left anterior sector consists of two segments: segment IV, which
is the quadrate lobe and segment III, which is anterior part of anatomical left
lobe. These two segments are separated by the left hepatic fissure or
umbilical fissure.
• Left posterior sector consists of only one segment II. It is the posterior part
of left lobe.

11. • Traditionally referred to as segment 1, the caudate lobe has been
divided into 2 segments: 1 and 9.
• Segment 1 refers to the Spiegel lobe, and segment 9 refers to the
paracaval portion and caudate process
• Reidel lobe refers to a ‘‘tongue-like projection of the anterior border
of the right lobe of the liver to the right of the gallbladder’’ below the
costal margin. It is not a true anatomic lobe, but is a normal variant
of segments 5 and 6

12. Brisbane 2000
• Liver anatomy is described in first-,
second-and third-order divisions.
• The third order divisions, or segments
(Sg), are referred to by Arabic numerals,
not Roman numerals.

13. Brisbane - I order
• First-order division divides the liver into the left and right hemiliver,
or left and right liver. The term lobe is not used because the division
between the right and left hemiliver is not an externally apparent
structure.
• The border, also referred to as a watershed, of the first-order
division is referred to as the midplane of the liver ( plane between
the IVCand the gallbladder fossa)
• Cantlie line is a misnomer, because the division between the
hemilivers is a three dimensional space, and therefore technically a
plane.
• The caudate lobe, also referred to as segment 1 is not included in
the first-order division.
• The terminology for surgical resection at the first-order division is
right or left hepatectomy or hemihepatectomy. To correctly classify
the resection, whether or not segment 1 was included in the
resection must be stipulated

14. I order division

15. Brisbane - II order
• Second-order division divides the liver into 4
sections based on the biliary and hepatic artery
anatomy.
• The right liver is divided into the right anterior
section (Sg 5,8) and the right posterior section
(Sg 6,7).
• The left liver is divided into the left medial
section (Sg 4) and the left lateral section (Sg
2,3). The terminology for resection is obtained
by adding -ectomy to the anatomic term (ie, left
lateral sectionectomy)

16. II order division

17. Addendum for
alternate second order division
• Based on portal vein anatomy rather than biliary and
arterial anatomy.
• Uses the term sector rather than section.
• The right lobe is divided as in the addendum system, but
given different names; segments 5 and 8 are referred to
as the right anterior sector or the right paramedian
sector, and segments 6 and 7 are referred to as the right
posterior sector or right lateral sector.
• Segments 3 and 4 are referred to as the left medial
sector or the left paramedian sector and segment 2 is
referred to as the left lateral sector or the left posterior
sector.

18. Brisbane – III order
• Third-order division refers to the individual
segments of the liver. The segments are
referred to as segment 1 to segment 9.
• Resection of a single segment is referred
to as a segmentectomy and resection of
any 2 contiguous segments is referred to
as a bisegmentectomy

19. III order

20. • Resection of segments 4 to 8 ( Sg 1) is referred
to as a right trisectionectomy (preferred term) or
extended right hepatectomy or extended right
hemihepatectomy.
• Resection of segments 2 to 5 and 8 ( Sg 1) is
referred to as a left trisectionectomy (preferred
term) or extended left hepatectomy or extended
left hemihepatectomy.

21. Problems with Brisbane
• Does not address the nomenclature of resections that do not
encompass a complete segment, sometimes referred to as
wedge resections or partial segmentectomies.
• Does not define gray zones between resections; that is, is a
right hepatectomy that includes only a portion of segment 4
classified as a right hepatectomy or a right trisectionectomy?

22. Caudate Lobe:Anatomic Location
• Space below hilum
• Proximity to
confluences
• Anterior to IVC
• From the level of HV
as they enter IVC
• Inferior edge of liver

23. Caudate Lobe

24. Caudate
• Caudate lobe itself can be divided into right, left, and
caudate process.
• Caudate lobe proper is located between the inferior vena
cava and the umbilical fissure
• Caudate process connects the caudate lobe to the right
hepatic lobe
• In 44%, 3 separate ducts drain each part. In 26% of
cases, the caudate process duct and the duct from the
right portion of the caudate form a common duct.
• In most cases, the caudate process duct drains into the
RHD (85%) and the left part of the caudate lobe drains
into the LHD (93%).

25. • The caudate lobe receives portal blood flow from both
the left and, to a lesser extent, the right portal systems
• Venous drainage occurs along its posterior aspect
directly into the IVC through multiple small branches of
variable size and location.
• Biliary drainage includes small tributaries to the right, but
is predominantly through the left hepatic duct.
• Isolated resection of segment 1 is technically demanding
because of its anatomical position posterior to the liver,
between the hepatic hilum and the inferior caval vein, in
close proximity to the middle and left hepatic vein
• Selective caudate segmentectomy can be done via an
anterior transhepatic approach or high dorsal resection

26. Anatomic Subclassification
• Papillary process or Spiegel lobe proper
– Protuberant portion to the left of IVC
– Seen through the hepatogastric ligament,
• Caudate Process
– Portion to the right of IVC
– Right border blends into the right hemiliver
• Paracaval portion
– Intimate contact with IVC
– Connects the Spiegel lobe to the caudate process

27. Anatomic subclassification

28. Segment IX ?
Couinaud 1994 used the term seg IX for an area on the dorsal sector
of the liver (caudate lobe) close to the IVC (paracaval portion)
The anatomy of the paracaval portion is the liver parenchyma ventral
to the hepatic IVC, between the Spiegel lobe and the right lobe,
adjacent to the middle hepatic vein ventrally. This portion was
classified by Couinaud as segment IX
•However in 2002 Couinaud and co-workers abandoned the concept
of seg IX as according to them no separate arteries, veins or ducts
can be identified for the right paracaval portion of the posterior liver
and because pedicles cross the proposed division between the right
and left caudate lobe
28

29. ANATOMY OF BILE DUCT
BRANCHES IN THE HILAR
AREA
Junction of anterior seg
duct and post seg duct to
form the RHD which in turn
joins the LHD at the hilar
confluence 53-72%
Post seg duct joining the
LHD 9-27%
Ant seg duct joins the hilar
conf forming 3 br type hilar
conf 7-14%
Ant seg duct joins the LHD
6-9% 29

30. CONFLUENCE VARIANTS Smadja C, Blumgart

31. Anomalies of IHBR

32. • The classic biliary anatomy appears in about 58% of the population and
consists of the right hepatic duct and left hepatic duct draining the right and
left lobes of the liver, respectively (Fig 6).
• The right duct branches into the right posterior hepatic duct, draining
posterior segments VI and VII, and the right anterior hepatic duct, draining
anterior segments V and VIII.
• The right posterior duct, which has a horizontal course, usually runs
posterior to the right anterior duct, which is more vertically oriented, and
fuses with it from a medial approach to constitute a short right hepatic duct.
• Segmental tributaries draining segments II–IV form the left hepatic duct.
• The fusion of the right and left hepatic ducts gives rise to the common
hepatic duct. The caudate lobe usually drains to the origin of the left hepatic
duct, or to the right hepatic duct.
• The cystic duct usually drains into the lateral aspect of the common hepatic
duct below its origin

33. RHD
• Right posterior sectoral duct is generally
oriented in a horizontal direction as opposed to
the right anterior sectoral duct, which runs in a
vertical direction.
• The posterior sectoral duct is typically more
superior and longer than the anterior duct.
• In most cases, the anterior sectoral duct drains
segments 8 and 5; however, in 20% of cases,
segment 8 joins the right posterior sectoral duct

34. LHD
• Compared with the RHD, less anatomic variation of the
LHD.
• Significant variation in bile ducts draining the left medial
section
• Usually the sectoral branches from the lateral and medial
sections join each other within the umbilical fissure to
form the LHD.
• Orientation of the LHD and left portal vein are typically
horizontal at the hilum before entering the umbilical
recess where they lie in a more vertical direction. The
LHD courses horizontally at the base of segment 4
superior to the left portal vein. It then joins the RHD
anterior to the portal vein bifurcation to form the CHD

35. Confluence pattern of RHD

36. RHD
• Supraportal pattern
– Right posterior sectional bile duct ran dorsally and
cranially to the right or the right anterior portal vein
and joined with the distal bile duct at its cranial side
• Infraportal pattern
– Right posterior sectional bile duct ran ventrally and
caudally to the right or the right anterior portal vein
and drained into the distal bile duct at its caudal side
• Combined pattern
– Some parts of the right posterior sectional bile duct
entered the distal bile duct supraportally and the
remaining parts of the right posterior sectional bile
duct joined with the distal bile duct infraportally.

37. Supraportal pattern
• Type A
– Right posterior sectional bile duct joined with the right
anterior sectional bile duct, forming the right hepatic
duct
• Type B
– Right posterior sectional bile duct entered the
confluence of the right anterior sectional bile duct and
the left hepatic duct
• Type C
– Right posterior sectional bile duct drained into the left
hepatic duct

38. Infraportal pattern
• Type D
– Right posterior sectional bile duct joined with
the right anterior sectional bile duct, forming
the right hepatic duct
• Type E
– Right posterior sectional bile duct entered the
common hepatic duct

39. Combined pattern
• Type F
– A portion of the right posterior sectional bile duct
joined with the right anterior sectional bile duct
infraportally, becoming the right hepatic duct, and the
remaining parts of the right posterior sectional bile
duct entered the right hepatic duct supraportally
• Type G
– portion of the right posterior sectional bile duct joined
with the common hepatic duct infraportally and the
remaining parts entered the left hepatic duct
supraportally

40. Summary - RHD

41. Confluence Patterns of the LHD
• Type H
– Left medial sectional bile duct drained into the left lateral
sectional bile duct
• Type I
– Left medial sectional bile duct entered the confluence of the left
lateral anterior and posterior segmental bile ducts
• Type J
– Left medial sectional bile duct joined with the left lateral anterior
segmental bile duct
• Type K
– Left medial sectional bile duct entered the hepatic confluence

42. LHD

43. Clinical implication – Ductal
anatomy
• Right hepatic duct was absent in 26%.
• When harvesting a donor without a right hepatic duct,
two or more orifices of the bile ducts will be present in
plane of transection of the graft. Biliary reconstruction of
these variants is complicated and technically difficult. It is
essential that both stumps must be reconstructed when
they are present
• Particular care must be taken in harvesting the left liver
from a donor with a type C or G variant. As the right
posterior sectional bile duct will be divided from the left
hepatic duct in these cases, oversight or ligation of the
stump of the right posterior sectional bile duct will lead to
biliary leakage or obstruction in the donor.

44. Surgical Anatomy of the Left Lateral Segment as Applied to Living-Donor and
Split-Liver Transplantation
Four specific patterns of left biliary
anatomy:
•segment 2 and 3 bile ducts unite
close to the umbilical fissure to form
a single LLS duct that receives a
single segment 4 duct medially
(55%)
• segment 2 and 3 bile ducts unite
medial to the umbilical fissure with
two parallel segment 4 ducts joining
the single LLS duct to form the left
hepatic duct (30%)
• segment 3 duct that receives the
duct from segment 4 and joins
segment 2 close to the hepatic hilum
(10%)
• and segments 2 and 3 ducts unite
lateral to the umbilical fissure to form
a short LLS duct that immediately
receives the segment 4 duct forming
the left hepatic duct (5%)
44

45. Summary
• In LDLT, the biliary anatomy of the donor usually is
evaluated using intraoperative cholangiography
• The surgeon must make a snap decision as to the biliary
anatomy and its relationship to the line of transection.
• When the right posterior sectional bile duct drains into
the left hepatic duct, it runs supraportally; and when the
right posterior sectional bile duct enters the common
hepatic duct, it runs infraportally.
• Familiarity with the variations of the hepatic confluence,
especially types B, C, E, G, J’, and K, will decrease the
likelihood of surgical misadventure.
Masayuki Ohkubo,Masato Nagino,Junichi Kamiya, Surgical Anatomy of the Bile
Ducts at the Hepatic Hilum as Applied to Living Donor Liver Transplantation.
Ann Surg 2004;239: 82–86

46. Vascular anatomy

47. CBD arterial supply
• Two major axial vessels along the lateral borders of the
supraduodenal CBD
– 3 o’clock and 9 o’clock arteries
• 8 small arteries with a diameter of 0.3 mm supplying the
supraduodenal CBD. These arteries arise from-
 Below – 60%
 posterior or anterior superior pancreaticoduodenal artery
 gastroduodenal artery
 retroportal artery
 Above – 38%
 right hepatic artery
 cystic artery
 left hepatic artery
 Rarely – 2%
 nonaxial supply from the common hepatic artery

48. • Hilar ducts
– Arterial branches from the right and left
hepatic arteries; form a rich network around
the ducts and are in continuity with the plexus
around the CBD
• Retropancreatic CBD
– multiple small branches from the posterior
superior pancreaticoduodenal artery

50. Surgical implications

51. Hepatic Venous anatomy

52. MHV
• Hepatic venous outflow of the median
sector(corresponding to Couinaud segments 5,
8 and 4) is drained mainly into the middle
hepatic vein
• As a result, preservation of MHV outflow
drainage plays an important role in LDLT with
the right lobe.
• However, inclusion of the MHV in the right lobe
graft and the necessity of MHV tributaries
reconstruction are still controversial

53. Right lobe graft - methods
• Two harvesting methods for right lobe grafts have been
proposed: an extended right lobe graft, in which the MHV
trunk is included in the grafts, and a modified right lobe
graft, in which only the MHV tributaries are included.
• Leaving the MHV with the remnant liver will place the
anterior segment (corresponding to segments 5 and 8) at
risk for congestion and this drainage problem can lead to
severe graft dysfunction and septic complications.
• In such cases, the reconstruction of MHV tributaries
have been recommended.

54. Deciding on MHV
• Kyoto group, using the three-dimensional
reconstructed images of the hepatic vascular anatomy,
divided the right lobe graft morphologically into two
types: one is a right hepatic vein dominant graft in which
the territory draining into the MHV is less than 40% of
the right lobe graft, and the other is a MHV dominant
graft.
• Their indication for a right lobe graft with or without the
MHV is based on dominancy of the hepatic vein, graft-to-
recipient weight ratio, and remnant liver volume
Kaneko T, Kaneko K, Sugimoto H et al. Intrahepatic anastomosis formation between the
hepatic veins in the graft liver of the living related liver transplantation: observation by
Doppler ultrasonography. Transplantation 2000;70:982-985.

55. MHV ?
• Sano et al reported that venous congestion in the right
liver graft can be assessed by temporary arterial
clamping and intraoperative Doppler ultrasonography.
They suggested the reconstruction of the hepatic vein or
its tributaries if the graft volume excluding the discolored
area under arterial clamping was estimated to be
insufficient for postoperative metabolic demand (the
remaining liver volume was less than 40% of the
standard liver volume).
• Kubota et al proposed if the congestive area of the liver
surface appeared after clamping of MHV tributaries and
the hepatic artery is larger than half of the surface of the
anterior segment, the vein should be reconstructed.

56. Preservation of MHV during
left hepatectomy
The key step is the accurate
identification of the intrahepatic
origin of the MHV, by IOUS
detection of the venous branches
originating from segments 4 (4b)
and 5
•It’s origin usually lies 2.5 to 3 cm
deep into the liver parenchyma.
•The parenchymal transection is
continued by following the
orientation of the main trunk of
the MHV up to the IVC, on the
left side of the vein securing and
cutting only the left branches,
which drain subsegments 4a and
4b. 56

57. Few techniques aiming to
preserve the MHV during left
hepatectomy
Classically, dissection of the
parenchyma is performed at
about 2 to3 mm to the left of
the main portal fissure,
dividing the left branches of
the MHV, which is kept
unseen.
The major drawback of this
technique is the risk of
accidental injury of the MHV.
Parenchymal dissection
along the MHV under visual
control reduces this risk and
also allows a better
oncological margin whenever
needed
57

58. Vessel diameter
• Other institutions concerned mainly about vessel
diameter.
• Gyu Lee et al indicated that when larger than 5
mm diameter, the reconstruction of MHV
drainage from the anterior segment is
recommended
• Mizuno et al suggested 7 mm as the
demarcation for reconstruction of MHV
tributaries.

59. IRHV
• Before transplantation, the size of the vein must be
determined as well as the distance between the main
right hepatic vein (at the confluence of the hepatic vein
with the inferior vena cava) and the drainage site of the
inferior right hepatic vein into the inferior vena cava.
• The size of the accessory inferior right hepatic vein is
important because it can affect the surgical approach. If
the cross-sectional diameter is greater than 5 mm, the
vessel has to be preserved and reanastomosed in the
recipient’s inferior vena cava; otherwise, it can result in a
congested graft and lead to organ rejection

60. IRHV
• The IRHVs are divided into superior, medial and inferior groups,
separately named the superior, medial and inferior right hepatic
veins according to the position of the IRHV entering the inferior vena
cava. The superior right hepatic vein mainly drains the superior part
of segment Ⅶ, and the medial right hepatic vein drains the middle
part of segment Ⅶ
•The smaller the diameter of the right hepatic vein, the larger the
diameter of the IRHV, and vice versa
•It is possible to perform anatomical resections removing the entire
right hepatic vein but sparing the right postero-inferior area. The
postero-inferior area of the right lobe can be preserved along with
the hypertrophic IRHV even if the entire major hepatic vein (MHV) is
resected
•The posteroinferior area of the right lobe can be preserved along
with the hypertrophic IRHV even if the entire main right hepatic vein
is resected during segmentectomy of Ⅶ and Ⅷ with right hepatic 60

61. Portal Venous anatomy

62. Portal vein br in the hilar area
Because the portal vein
develops during the very
earliest part of the gestational
period, few variations are found
in the portal vein branches, and
variations in the anterior
segmental branches of the
portal vein (P5,P8) are very
rare. Three principal portal vein
branching patterns found in the
hilar area
→ common type – anterior
segmental br joining the
posterior seg br to form the
RPV 74-84%
→ the 3 br type in which the
anterior seg br joins the PV
conf 8-12%
→ Left br type in which
anterior seg br joins the LPV 9-
17%
62

63. PV VARIANTS

64. • Failure to recognize PV trifurcation lead to loss of supply
to right anterior or right posterior segment. It needs
division on right side of trifurcation.
• Non division of main portal trunk with absence of
separate main left PV is absolute C/I to right lobe LDLT.

65. Biliary-Vascular Sheaths (PLATE)
• Fusion of the Glisson capsule with the
connective tissue sheaths surrounding the biliary
and vascular elements.

68. HILAR PLATE
• Is bounded above by S4a, on the right by the
Rouviere sulcus (a landmark demarcating the
division between S6 and S5) and the cystic
plate, and on the left it is continuous with the
umbilical plate.
• The anterior Glisson’s sheath generally runs
behind the junction between the cystic plate and
the hilar plate, and the posterior-inferior
Glisson’s sheath runs behind the Rouviere
sulcus.

69. CYSTIC PLATE
• The cystic plate is located in the gallbladder bed
and is continuous with the capsule of S5, S4a,
and the Glisson’s sheath of the anterior segment
of the liver.

70. UMBILICAL PLATE
• The umbilical plate is located along the inferior
edge of the ventral surface of the umbilical
fissure.
• It contains the ducts and blood vessels of S2,
S3, and S4, and is continuous with the round
ligament inferiorly.

71. LEFT DUCT EXPOSURE
• Its also called HEPP COUINAUD approach.(1st
to describe transfissural (intrahepatic) approach
through main fissure)
• For high biliary stricture in BDI and
cholangiocarcinoma. (dense adhesions)
• Length of left hepatic duct is reflected by the
length of the base of the quadrate lobe.
• It may be hazardous in case of atrophy-
hypertrophy liver lobes and deep hilus which
displaced upwards.

72. Cont…
• This approach is difficult if quadrate lobe is large
or carcinoma involving of left duct.
• it is ideal for repair of type El to E3 injuries.
(confluence is patent)
• Resection of segment 4 is very useful when the
liver is overhanging the upper ducts, as has
recently been advocated by Mercado et al. (type
E3)- confluence intact.

73. LIGAMENTUM TERES APPROACH

74. LEFT DUCT EXPOSURE

75. LOWERING
HILAR PLATE
• Biliary confluence and
left hepatic duct exposed
by lifting segment IV
upward after incision of
the Glisson capsule at its
base.

76. • The hilar plate is detached from the liver
parenchyma by dissecting in between the left portal
pedicle and liver tissue.
• The umbilical fissure and plate is the site of origin of
segmental and sectoral pedicles to the left liver.
Its anatomic landmarks are the falciform ligament
and the left longitudinal sulcus.
• The sulcus of Rouvière is an irregular fissure in
continuity with the right hilum.
Following this structure leads to the pedicles of
segments V and VI and further deeply and
posteriorly to the pedicles of segments VII and VIII.

77. EXPOSURE OF RIGHT DUCT
• Indicated in some cases of hilar
cholangiocarcinoma, the planned surgical
procedure—partial hepatectomy or segment III
duct bypass —seems impossible much more
hazardous and imprecise than that of the left.

78. Hepatectomy: the posterior intrahepatic
approach (launious)- RIGHT DUCT
• reliant upon early division of the hepatic pedicle
extrahepatically.
• This allows delineation of the line of resection for
hepatectomy and segmentectomy.
• approach is through the dorsal fissure between
segments IV and I, and segment VIII and the
new segment IX described by Couinauds.

79. • The main hepatic pedicle is clamped en masse and
incisions made into the liver capsule in two regions,
the first posterior to and the second anterior to the
hilus.
• anterior incision is made in front of the hilum and
through the liver capsule from the gallbladder bed to
the umbilical fissure.
• An identical incision is made posterior to the hilum,
the surgeon’s index finger is insinuated through this
incision, and liver tissue is blindly pushed away until
the superior surface of the confluence is reached.

81. EXPOSURE OF ISOLATED RIGHT
DUCT IN BDI
• Right and left duct are in same coronal
plane.(the key to the dissection is to stay in the
coronal plane of the left hepatic duct.)
• To find the bile duct within the sheath of the right
portal pedicle, which also contains the portal
vein and hepatic artery, the cystic plate must be
detached from the anterior surface of the sheath
of the right portal pedicle.
• Base of segment 5 must be cored out to expose
right portal pedicle.

84. Thank you..