This document provides information about left hepatectomy surgery. It describes: 1) The anatomy relevant to left hepatectomy, including identification of the left hepatic artery and left portal structures. 2) The surgical technique, which involves hilar dissection, mobilization of the left liver, and liver resection using either extrahepatic or Glissonian pedicle transection methods. 3) Key steps like cholecystectomy, identification and ligation of vessels, and parenchymal transection using techniques like Pringle maneuver to control bleeding.

1. DR. BINEET KUMAR YADAV
HBP&LT SURGERY
PHASE-B
BSMMU

3. Benign Liver Tumor
Haemangioma
Adenoma
Cystadenoma
Malignant Liver Tumor
HCC
Cholangiocarcinoma
Metastasis
Carcinoma Gall Bladder
Benign Conditions
Intrahepatic Stones
Caroli’s Disease
Hydatid Cyst
Liver Cyst
Liver Trauma
LDLT

4. Left hepatectomy
is resection of
segments
2, 3, and 4 ± 1

5. Routine blood tests
Full blood count
Urea and Electrolytes
Liver function tests
Coagulation screen
C-reactive protein (CRP)
Blood grouping
Tumor marker -CEA, CA19-9, and AFP
A low molecular weight heparin may be administered
on the night before surgery to reduce the risk. of deep
vein thrombosis and pulmonary embolism.

6.  The patient is positioned supine with the arms
extended out at right angles allowing for easy
peripheral vascular access and monitoring.
 Incisions-
Bilateral subcostal incision (chevron)
J incision (Makuuchi)
Inverted-T incision(Mercedes)
Right/left subcostal incision(Kocher/Kehr)
Inverted L incision

7. An inverted L-shaped incision is
made in the upper abdomen,
begins cephalhad to the xiphoid,
extends to 1 cm above the
umbilicus, and than extends 4 cm
laterally.
If any difficulty is encountered in
division of the left triangular
ligament, an inverted T-shaped
incision would provide good
access.

9. The most important points to bear in mind in relation
to left hepatectomy are
1) a precise recognition of the surgical anatomy of the
vascular structures of the liver, especially the bile
duct
2) recognition that the procedure consists of the
following three parts: hilar dissection, mobilization
of the left liver, and liver resection
3) an understanding that these steps need to be
accomplished with great care to control bleeding and
to avoid injury to the vessels supplying the right
hemiliver

10. Two method-
1) Extrahepatic
dissection
2) Glissonian Pedicle
Transection.
Initial step is
cholecystectomy after
ligation and division of
cystic duct and cystic
artery.

11. Identification of LHA by opening the peritoneum covering
on left side of HDL at base of umbilical fissure.
After confirming by pulsation or by doppler LHA is taped,
ligated & divided.
MHA is ligated and divided in same manner.

12. LPV encircled, taped & dissected as far as root of
RPV.
Some of the portal venous branches to caudate lobe
are secured to obtain space and if no enough space
then vascular clamp applied and each stump closed
by 5-0 or 6-0 prolene suture.
Demarcation line is seen on liver surface.
Left Hepatic duct is identified just above the Portal
vein

14. Alternatively, the LHD
can be divided after
completion of the
parenchymal transection.

15. Alternative to extrahepatic dissection of the
hilar structures.

16. If the caudate lobe is to be preserved,
intrahepatic dissection is performed at the base
of the umbilical fissure.
When the caudate lobe is to be removed, the left
portal pedicle is divided near the bifurcation,
taking care not to ligate the bile duct or the
artery supplying the right hemiliver.

17. The falciform, right and left coronary, and left
triangular ligaments are incised to mobilize the
left lateral section.
It also exposes the suprahepatic vena cava as well
as extrahepatic segments of the LHV & MHV.
Division of the left coronary ligament by elevation
and caudal traction of the left lateral section with
the surgeon’s right hand placed behind the section

20. After mobilization of the left lateral section to the
right, the lesser omentum is totally divided.
The ligamentum venosum is ligated and divided
at the junction with the LHV.
Here a better view is obtained to dissect the
common trunk of the MHV and the LHV.

21. To perform caudate lobectomy dissection of the
caudate lobe from the inferior vena cava is carried
out.
Along the lateral border of the Spiegel’s lobe, the
peritoneum is incised, ligated and divided.
The inferior vena cava ligament which fixes the
caudate lobe to the cava from behind, is ligated and
divided, because it sometimes contains vascular
structures

23.  Hepatic veins draining the caudate lobe (short
hepatic vein) are ligated and divided.
 Because the extrahepatic portion of the vein is
usually very short, a transfixing suture is
placed, or it is clamped and oversewn with a
4-0 or 5-0 polypropylene suture on the caval
side, to avoid the ligature slipping off.

24. Parenchymal dissection is begun by CUSA on the
inferior surface by lifting the left lateral section
ventrally after marking by electrocautery over
demarcation line on liver surface.
Continued along the middle hepatic vein, the
landmark for left hepatectomy, in a caudal to
cranial direction under intermittent inflow
occlusion i.e. Pringle maneuver (15 min of
occlusion followed by 5 min perfusion)

25. During parenchymal transection under the inflow
occlusion technique, it is important to control the
backflow of blood from the MHV using the
surgeon’s finger by compressing it from behind.
The main trunk of the MHV is exposed on the
transection plane until its junction with the vena
cava.
At this point, the transection plane shifts towards
the left if the caudate lobe is preserved.

27. When caudate lobe is to be removed, the transection
plane runs vertically along the demarcation line on
the liver surface, left border of the MHV & anterior
surface of the IVC.
The surgeon’s left index finger lies on the anterior
surface of the IVC for this step.
At the end of the parenchymal transection, the LHV
is ligated and divided, or clamped, divided, and
oversewn with a 4-0 polypropylene suture at its
root.

28. Care should be taken not to damage or narrow the main
trunk of the MHV

29. For the bile leakage test, a catheter is inserted
through the cystic duct and saline is passed.
If a leak is present, it is repaired with ligatures or
fine sutures.
A closed drain is placed on the cut surface of the
liver.