Left Hepatectomy

Chapter 32 Left Hepatectomy



Jay A. Graham, MD, Lynt B. Johnson, MD



INTRODUCTION


In regard to the performance of a left hepatectomy, the operative concepts remain unchanged from that of a right-sided resection. While technically easier than a right hepatectomy, the detailed understanding of liver anatomy is paramount to reproducibly performing safe left-sided hepatectomies. Moreover, the surgical pitfalls we discuss should prompt a thorough examination of hepatic anatomy as it relates to form and function to prevent the forthcoming outcomes.



INDICATIONS



• Benign tumors (e.g., hepatic adenoma or symptomatic hemangioma)

• Malignancies

• Primary liver cancer (hepatoma or cholangiosarcoma)

• Metastases


OPERATIVE STEPS



Step 1 Operative incision

Step 2 Division of falciform ligament

Step 3 Division of left triangular and coronary ligaments

Step 4 Division of hepatogastric ligament

Step 5 Ligation and division of left hepatic artery and left portal vein branch

Step 6 Liver parenchymal division

Step 7 Left hepatic duct division

Step 8 Middle and left hepatic vein division


OPERATIVE PROCEDURE



Operative Incision


Typically, a right subcostal or chevron incision with midline extension is used to provide excellent exposure during a left hepatectomy.



Division of the Falciform Ligament


The falciform ligament and ligamentum teres should be divided so that the left lobe can be fully mobilized.



Division of the Left Triangular and Coronary Ligaments



Injury to the Phrenic Vessels


As the phrenic vessels course along the diaphragm in an oblique fashion, they can be inadvertently transected during dissection of the left coronary ligaments (Fig. 32-1). During this phase of left lobe mobilization, it is best to hug the surface of the liver. See Section IV, Chapter 31, Right Hepatectomy.


image

Figure 32-1 The left coronary and triangular ligaments have been divided to reveal the bare area of the liver (↓). The left phrenic vein (image) is prominent and observed to be coursing through this area. After dividing the left coronary and triangular ligaments, the surgeon rotates the left lobe medially to reveal the remnant of the ligamentum venosum as it enters the left hepatic vein just cephalad to the caudate lobe (image).



Injury to the Inferior Vena Cava



• Consequence



During division of the coronary and left triangular ligaments, the inferior vena cava (IVC) may be injured with medial dissection.

Grade 5 complication


• Repair



Management is discussed in Section IV, Chapter 31, Right Hepatectomy.


• Prevention



Dissection of the coronary ligaments should be done with great care to minimize the chance of an inadvertent IVC puncture.


Esophageal Injury



• Consequence



The esophagus lies at the inferior edge of the triangular ligament (Fig. 32-2). Esophageal injury may occur during stray dissection in this area.

Grade 2/3 complication

image

Figure 32-2 The proximity of the left triangular ligament with the esophagus. The surgeon must be aware of this spatial anatomy to avoid inadvertent esophageal injury during left triangular ligament division.



• Repair



Unrecognized esophageal injuries can be catastrophic. Therefore, the esophagus should be inspected carefully and primarily repaired immediately if an injury is found. Drains should be left in the vicinity and the patient kept on postoperative antibiotics that target enteric organisms.


• Prevention



The left triangular ligament should be taken down at the peritoneal reflection of the left lobe. Dissecting along the inferior edge of the liver should keep the surgeon superior to the esophagus. A right angle can be used to pull the triangular ligament and peritoneal attachments away from crucial structures during this mobilization.


Division of the Hepatogastric Ligament



Injury to an Accessory or Replaced Left Hepatic Artery


An accessory or replaced left hepatic artery branches off the left gastric artery. The aberrant artery lies in the hepatogastric ligament and can be injured during dissection (Fig. 32-3). The incidence of this anomaly is approximately 12.5%.1


image

Figure 32-3 A replaced left hepatic artery should be recognized and controlled before division of the hepatogastric ligament to avoid potential bleeding.



• Consequence



Uncontrolled bleeding may result from inadvertent transection of an aberrant left hepatic artery traveling in the hepatogastric ligament.

Related posts:

  1. Isolated Limb Perfusions and Extremity Amputations
  2. Traumatic Brain Injury
  3. Open Inguinal Hernia Repair with Plug and Patch Technique
  4. Bronchial and Vascular Sleeve Lobectomy

Stay updated, free articles. Join our Telegram channel
Tags:
Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Left Hepatectomy

Full access? Get Clinical Tree
Get Clinical Tree app for offline access