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The right hepatic lobe is freed up from the diaphragm and rotated medially away from the diaphragm, exposing the small hepatic veins communicating with the inferior vena cava. These small vessels are carefully and securely ligated (Figure 6A). The cava ligament must be divided to expose the inferior border of the right hepatic vein. Caution must be executed as an accessory right hepatic vein may traverse this ligament and drain into the inferior vena cava (IVC) (Figure 6B). The major right hepatic vein is exposed.

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A loop is passed around the large right hepatic vein, and the liver tissue gently pushed away to permit the application of two curved Cooley vascular clamps to the vein. Sufficient vein must extend beyond the vascular clamps in order to secure the open ends. After the vein has been divided, two rows of nonabsorbable vascular sutures are used to secure the ends of the right hepatic vein (Figure 7A). Alternatively a vascular stapler may be used (Figure 7B).

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The concave line of demarcation following the color change subsequent to ligation of the blood supply may be superficially outlined with a cautery. Starting at the inferior border of the line of demarcation, deeply placed mattress sutures are inserted to control bleeding. The mattress sutures must be tied to compress the liver substance but not to crush it, thus leading to more bleeding. After three or four mattress sutures are placed on either side of the lower end of the zone of demarcation, the liver tissue is divided with an ultrasound dissector, laser, or electrocautery unit (Figure 8). Larger vessels and branches from the middle hepatic vein may require double ligation. Surface coagulation may be obtained with an argon beam electrocautery device. Alternatively, the hepatic parenchyma can be transected using multiple applications of an endoscopic cutting linear stapler with vascular loads. This approach should only be used after clear mapping of the internal vascular anatomy using the ultrasound probe. After all bleeding and bile leakage has been controlled (Figure 9), the omentum may be brought up to cover the raw surface of the left lobe. Sufficient sutures are taken to secure the omentum in place.

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The pathologist examines the specimen to determine adequate clear ...

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