Chapter 32 Left Hepatectomy
OPERATIVE PROCEDURE
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.
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.
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.
• 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