Chapter 45 expertly describes the preoperative evaluation, patient selection, integration of chemotherapy, and results of resection for colorectal cancer (CRC) metastatic to the liver. Below are comments about the technique of resection.
Most liver resections can be done with a right subcostal incision extended vertically in the midline to the xyphoid process. Patients prefer this incision to the rooftop or “Chevron” incision that rarely is needed. Inspection and palpation should exclude extrahepatic disease and assess intrahepatic disease. At this point, intraoperative ultrasound (IOUS) should be performed to determine the size and location of all tumor nodules. IOUS can help plan the resection to maximize the chance of obtaining a negative margin. With no contraindication to resection, the appropriate resection can be performed. Resections depend on the segments that need to be removed. A diagram of Couinaud's segments is in Fig. 46B-1.
The nomenclature for resections depends on the segments removed as summarized in Table 46B-1. Right hepatectomy is the most common major liver resection and it is described in detail below.
Table 46b-1: Definitions of Liver Resection ||Download (.pdf)
Table 46b-1: Definitions of Liver Resection
|Definition||Couinaud's Segments Removed|
|Right hepatectomy||V, VI, VII, VIII|
|Left hepatectomy||II, III, IV|
|Right trisegmentectomy (right lobectomy)||IV, V, VI, VII, VIII|
|Left trisegmentectomy||II, III, IV, V, VIII|
|Left lateral liver resection (left lobectomy)||II, III|
The functional division of the liver and the segments according to Couinaud's nomenclature.
The right side of the liver is mobilized by dividing the right triangular ligament and the anterior and posterior leaflets of the right coronary ligament. The inferior vena cava (IVC) is exposed and small branches from the liver to the IVC are ligated and divided to facilitate exposure and avoid tearing. At this point, attention is focused on the porta hepatis for the hepatoduodenal dissection.
The gallbladder is removed and the bile duct is traced to the liver. The hepatic artery is identified and the right hepatic artery (RHA) isolated, usually anterior to the hepatic duct but occasionally posterior to the hepatic duct. The RHA is ligated and divided, carefully protecting the main and left hepatic arteries. The right hepatic duct is divided and the hepatic duct can be lifted anteriorly to the left to expose the portal vein (Fig. 46B-2). The junction of left and right portal vein (RPV) is exposed cautiously and a vessel loop is placed around the RPV. It is preferable to ligate and divide the RPV with sutures or a vascular stapler that ligates and cuts. At this point, inflow control is achieved and the liver will quickly demarcate such that the right liver will discolor. It now is reasonable to maximize outflow control.