Plate 113
###### Figure 9

The left branch of the portal vein is now exposed. The area of the bifurcation of the portal vein is carefully freed up and the left branch mobilized for a sufficient distance to permit the application of a pair of curved Cooley vascular clamps without compromising the bifurcation of the portal vein. The left branch of the portal vein is divided a short distance beyond the clamps to permit closure of the proximal end of the branch of the portal vein with a continuous horizontal mattress suture of 4-0 synthetic nonabsorbable suture that is then run back as an over-and-over suture after the method of Cameron (Figure 6). If the caudate (Segment 1) is to be preserved, the surgeon must take care to divide the left portal vein distal to the caudate branch at the base of the umbilical fissure. Alternatively, the portal vein can be divided using a vascular stapler. A final inspection determines that the blood supply to the right lobe is functioning normally.

The blood loss should be lessened if the left hepatic vein is ligated before the liver tissue is divided. The left hepatic vein is freed of liver substance until a sufficient distance is gained to permit the application of a pair of long curved Cooley vascular clamps. The left lateral segment (Segments 2 and 3) can be lifted to expose the ligamentum venosum. When this is divided at its most cranial extent, a window is opened along the inferior border of the left hepatic vein as well as the middle hepatic vein depending upon their point of convergence. The path of the middle hepatic vein must be visualized as separate from the left hepatic vein. The end of the vein projecting beyond the clamps is closed first with a continuous mattress suture and then back with an over-and-over suture (Figure 7). The clamps are removed and a final check is made that the proximal caval end of the divided left hepatic vein is secure. A vascular stapler may be utilized to control the left hepatic vein.

A line of demarcation between the right and left lobes develops after the left hepatic vein has been ligated. This line tends to curve in a concave manner to the left until the dome of the liver is reached. Ultrasonic dissecting instruments are available for dividing (Figure 8) and aspirating the liver tissue with easier exposure for ligation of the larger ducts and vessels, especially the venous branches of the median ...

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