The ability to resect the caudate lobe in isolation is considered the ultimate expertise in liver resection. This presentation deals with all the feasible approaches to caudate lobe.

1. Caudate Lobe Resection
Dr Harsh J Shah
MS, DNB(GI), MCh (GI),
FMS, FALS
Kaizen Hospital
Ahmedabad

2. Scheme of presentation
■ Anatomy
■ Indications
■ Types
■ Approaches

3. Introduction
■ Caudate lobe is the first segment of liver in the Couinaud’s
classification.
■ Approach of segment I is the most difficult of all the segments
of the liver
■ Caudate lobe has been considered as a “no-man’s land”
■ In 1990 Lerut et al. reported first “Isolated complete resection
of caudate lobe”

4. Dodds et al. AJR 1989

5. Location of Caudate lobe

6. ■Caudate lobe (Seg I) is the
dorsal portion of the liver
that posteriorly embraces
the IVC
■Lies between the major
vascular structures
-Posteriorly IVC
-Inferiorly portal triad
-Superiorly MHV and LHV

7. 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
– relation with seg 7/6
● Paracaval portion
– Intimate contact with IVC
– Connects the Spiegel lobe to the caudate process
– relation with set 4

8. Anatomic subclassification

9. Separate liver by itself
■ Blood Inflow
– RPV/RPSV/LPV
– Branches of RHA/LHA
■ Biliary drainage
– RHD/Confluence/LHD
■ Venous Drainage
– IVC
– Junction of MHV/LHV

10. Three Porta Hepatis - Chinese literature

11. Normal CT

12. Hemangioma

13. Indications for caudate lobe resection
–Caudate lobe HCC or adjacent tumor invading caudate
–Metastasis to caudate lobe (colonic, Adrenal)
–Cholangiocarcinoma
–Carcinoma of Gall Bladder with SOJ
–Hepatolithiasis of caudate lobe

14. Classification of Caudate resection
■ Isolated : Partial/Complete caudate lobe
resection - HCC/Mets
■ Combined : Partial/Complete resection of the
caudate lobe with left / Right lobe (for Hilar
cholangiocarcinoma)

15. Combined left Hepatectomy

16. Combined Right Hepatectomy

17. Approaches to caudate lobe
1.Left side approach
2.Right side approach
3.The combined approach ( combination of left and right)
4.Anterior Transhepatic approach

18. Left side approach
–Small tumors situated in
Spiegelian lobe
–when caudate lobe was to be
resected combined with the left
liver (Left lateral
segmentectomy / lef t hemi-
hepatectomy / left
trisegmentectomy )

19. Right side approach
■ Caudate process tumour
■ When the caudate lobe is resected together with the
right liver, mostly right Hemihepatectomy.

20. Anterior Transhepatic approach
1. Large caudate tumours compressing IVC
2. Major HVs are compressed by the tumor

23. Transection line
■No well defined landmarks between the paracaval portion and
the Rt.posterior segment
■Tip of the caudate lobe to the right border of the caudate
process
■Transection plane is oblique
slanting from the
LHV to the RPV

25. Measures for Safe Resection of Caudate Lobe
■ Tumors located around the hepatic hilum or near the IVC
remains technically difficult, even if the tumor is small.
■ Major problems :
1. Dissection and control of Retrocaudate veins
2. In large tumors, Controlling bleed from MHV

26. Measures for safe caudate resection
1. Selection of appropriate skin incision
2. Adequate mobilization of the liver
3. Preparatory placement of tapes for Total Hepatic Vascular exclusion
4. Selection of the ideal route for hepatectomy based on the site of the
tumor and the combined removal of multiple lobes if necessary
5. Anterior Transhepatic approach ,made it possible to perform
isolated complete caudate lobe resection for extra-ordinarily difficult
cases

27. THANK YOU

28. Conclusion
● Access to and resection is determined by
– Tumor location and hepatic function
● Left-sided approach
– tumors located at Spiegel’s portion
● Right sided approach
– Tumours in paracaval or caudate process
● Combined approach
– Larger tumours
– Concomittant hepatic resection

29. LEFT SIDED
APPROACH

30. Left sided approach: Indications
Tumour arising from papillary process or
spread into the left part of the caudate lobe
(types 1 and 2 lesions)
Am J Surg 2008; 196:245-51
J Chir 1991;128:533–40

31. Left sided approach: Technique
● Opening of the lesser
omentum
● Assessment of CL
● Mobilization of left
hemiliver
● Division of attachments
to left of CL
Ligation and dissection of all short hepatic veins
Isolation of the Spiegel lobe from the lateral segment

32. Mobilization of Caudate lobe
● Left lobe is mobilized and turned
to the right
● Divide the ligamentous
attachments on the left and
mobilize the tip of the CL and its
left lateral margin from the IVC
before division of the caudate
veins

33. Inflow control
● Lower the hilar
plate to display
caudate branches
● Dissection of blood
supply at the base
of the umbilical
fissure

34. Outflow control
● Dissection and isolation of IVC
● Ligation of short hepatic veins
– From the left side, proceeding
– Caudal to cranial direction.
● Abn LHA
● Vein of the Spiegel lobe secured carefully
● Ligation of veins on IVC using vasc clamp

35. When to stop proceeding from left?
● If the CL is found to
embrace the IVC
posteriorly
● Bulky tumor within the
caudate lobe upward
mobilization is
hazardous.
● Retrohepatic veins
approached from the
right side

36. Parenchymal trasection
● Dissection of ductus
Arantius near the LPV
● Good view
● Resected along the
LHV & MHV to right
direction till dorsal
semicircle of the RHV
is exposed

37. RIGHT SIDED
APPROACH

38. Right sided approach:
Indications
● Types 3 through 5 lesions
● Complete exposure of the
anterolateral aspect of the IVC for
the outflow control from the
caudate lobe is better achieved
using a right lateral approach
● Well-developed retrocaval process
Am J Surg 2008; 196:245-51
J Chir 1991;128:533–40

39. Right sided approach
● Inflow dissection
– portal branches to the CL are ligated and
dissected from the right side of the hilum
● Complete mobilization of right lobe
● Exposure of RHV

40. Right sided approach
● Rotation of right
hemiliver
● Outflow occlusion
– Ligation of the short
hepatic veins:
caudal to cranial
● Parenchymal
transection

41. COMBINED
APPROACH

42. Anterior approach
● When isolated complete resection of the
caudate lobe is indicated
● Non-cancerous parenchyma is preserved
● Tumor is closely attached to the hepatic vein
● Characteristics
– liver is split through the mid-plane into two halves,
so as to fully expose the caudate lobe
Clinics 2009;64(11):1121-5

43. Anterior approach: Technique
● Complete mobilization of the liver
● Dissecting and ligating the short hepatic
veins caudal to cranially
● Encircle the supra and infrahepatic IVC
● Splitting the mid-plane, exposing the anterior
surface of the paracaval portion and the hilar
plate

44. Anterior approach: Technique
● Splitting the mid-
plane
● Ligating and
dividing the asc
caudate portal
triads

45. Anterior approach: Technique
● Separating the caudate lobe from the major
hepatic veins

46. Anterior approach: Technique
● Detaching the caudate lobe from the
neighboring liver parenchyma
● There are no large branches that must be
ligated
● Isolated complete caudate lobe is resected
● Two halves of liver were sutured together