(1)
Department of General Surgery, Sir Run Run Shaw Hospital Zhejiang University, Hangzhou, China
Knowledge of the anatomy of the liver is most important for surgeons to perform liver resection. It includes perihepatic ligaments, the biliary system, the portal vein system, the hepatic vein system, and the hepatic artery system (Fig. 1.1). Due to the different viewing angles in open liver resection and laparoscopic liver resection, the laparoscopic view of the liver’s anatomy might be a little different from the open condition.
Fig. 1.1
Major structures which should be properly managed in anatomical hepatectomies. (A) Biliary system; (B) Portal vein system and hepatic artery system; (C) Hepatic vein system
1.1 Perihepatic Ligaments
The observation port is usually located infraumbilically or supraumbilically, and the liver is observed and manipulated from the middle abdomen (Fig. 1.2). The hepatoduodenal ligament (HDL) can be exposed by mobilizing the liver upward by the traction of the round ligament (RL) or/and the gallbladder (GB) (Figs. 1.3 and 1.4). The RL (Fig. 1.5), the falciform ligament (FL) (Fig. 1.6), and the hepatocolic ligament (HCL) (Fig. 1.7) can be visualized and be divided firstly in laparoscope. The lesser omentum (LO) could be exposed by elevating the left lobe (LL) of the liver (Fig. 1.8). The left triangle ligament (LTL) can be exposed by pulling the left lobe to the right with a forceps (Fig. 1.9). The left coronary ligament (LCL) can be fully exposed after dividing the LTL (Fig. 1.10). It also can be exposed by pressing LL downward after dividing the FL (Fig. 1.11). The hepatorenal ligament (HRL) should be divided in right hemihepatectomy. It could be exposed by elevating the right lobe of the liver (RLL) or by pulling the right lobe to the left (Fig. 1.12). The right triangle ligament (RTL) and the right coronary ligament (RCL) might be the most difficult to expose in laparoscope for the limited space in the right upper quadrant. Before exposing them, RLL should be fully freed; the RL, FL, HCL, HRL, and even some short hepatic veins (SHVs) in the right wall of the inferior vena cava (IVC) should be divided; and RLL should be pushed to the left with forceps or a retractor to expose RTL (Fig. 1.13) or be pressed downward to expose RCL (Fig. 1.14). Additionally, in the division of LCL or RCL, inferior phrenic veins should be taken care of to avoid bleeding (Fig. 1.15).
Fig. 1.2
The view of the liver observed from the middle abdomen
Fig. 1.3
The HDL is exposed by the traction of RL with a forceps