Plate 111

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.

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).

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.

The pathologist examines the specimen to determine adequate clear margin. The structures going into the left lobe are inspected to ensure that no structures are obstructed by angulation.

The falciform ligament is reapproximated to ensure stability of the left liver lobe. Closed system Silastic suction drainage may be used.

Routine surgical closure procedures are followed with placement of closed suction catheters.

Daily blood and liver function studies should be carried out. Significant blood loss from drains may require replacement. Meticulous attention must be paid to minimizing infectious risks. Leakage of fluid from the wound should not be tolerated and aggressively corrected. If there is a bile leak of greater than 100 mL/day, then an endoscopic biliary start should be considered. If there is an ascites leak, the wound should be revised. Long-term follow-up should include frequent examinations with periodic liver function tests and CEA assays for patients with colon cancer. Rising abnormal values will signal the need for complete reevaluation, as described under Indications.