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INDICATIONS

Malignant tumors involving the right liver with extension into the medial section of the left liver (segment 4) are an indication for extended right hepatectomy (also known as a trisectionectomy). This is a major surgical procedure that requires a highly skilled team trained in this field.

PREOPERATIVE PREPARATION

A comprehensive evaluation of the overall health status, oncologic appropriateness, and anatomic resectability is critical to appropriate patient selection. In general, a lesion is considered resectable if negative margins can be obtained while leaving an adequate amount of functional liver parenchyma with hepatic arterial and portal venous inflow, venous outflow, and biliary drainage. Given the volume of liver anticipated to be removed during extended hepatectomy, all patients should be evaluated with liver volumetry based on high-quality thin-cut contrast-enhanced computed tomography. The remaining liver (i.e., segments 2 and 3 ± segment 1) should comprise at least 20% of standardized total liver volume for patients with normal liver function, 30% in those with compromised liver function (e.g., patients with extensive systemic chemotherapy or hepatic steatosis), and 40%–50% if cirrhosis is present in order to minimize the odds of posthepatectomy liver failure. If the future liver remnant is found to be insufficient, then right portal vein embolization should be performed to facilitate hypertrophy of the remaining liver.

ANESTHESIA

General anesthesia with low central venous pressure is recommended. Excellent venous access and arterial monitoring are necessary.

POSITION

Patients are placed supine on the operating table with the arms extended for access as needed by the anesthesiologist.

OPERATIVE PREPARATION

The skin of the thorax and abdomen is prepared because the incision may extend from over the lower sternum to below the umbilicus. Then a time out is performed.

INCISION AND EXPOSURE

A long right subcostal incision that extends across the left subcostal region is commonly selected. Alternatively, an inverse L incision provides excellent exposure. A long midline incision starting above the xiphoid and extending below the umbilicus also may be used. This procedure requires liberal exposure.

DETAILS OF THE PROCEDURE

The extent of tumor involvement of both the right lobe and the medial portion of the left lobe is verified by inspection, bimanual palpation, and ultrasonic imaging (FIGURE 1). The abdomen is also inspected to rule out extrahepatic disease.

The liver is mobilized by dividing the falciform ligament as well as the right and left coronary and triangular ligaments (FIGURE 2). When mobilization of the liver has been completed, the procedure outlined for a right hepatectomy is followed (see Chapter 84). Ligation of the cystic artery and cystic duct is performed, and the gallbladder is removed, resulting in better exposure of ...

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