INFLOW CONTROL

The hilar plate is lowered. The left hepatic artery is ligated and divided. Any accessory or replaced hepatic artery arising from the left gastric artery is similarly ligated.

Dissection at the base of the umbilical fissure exposes the left portal vein. It should be controlled at this point and not at its origin from the main portal venous trunk. If the caudate lobe is to be removed together with the left lobe, the vein is secured below the takeoff of the caudate branches. If the caudate lobe is to be preserved, the vein is divided distal to the takeoff of the caudate branch (see Fig. 3-14). The left hepatic duct usually is easily identified just above and behind the left portal vein and can be encircled with a suture and divided as it curves into the umbilical fissure. These steps are illustrated in Fig. 4-1. A line of demarcation in the Glissonian plane extending from the gallbladder fossa to the left of the vena cava is now visible on the liver surface (Fig. 4-2) and is marked with a diathermy.

Figure 4-1 A, Dissection for left hepatectomy at the base of the umbilical fissure. B, Left hepatic duct (LHD) is divided at the base of the umbilical fissure. A₁, Point of division of the left hepatic artery (LHA) for concomitant removal of caudate lobe; A₂, point of division of LHA for left hepatectomy; P₁, point of division of the left portal vein (LPV) for left hepatectomy and caudate lobectomy; P₂, point of division of LPV for left hepatectomy alone.

Figure 4-2 The left liver has been devascularized before parenchymal transection for left hepatectomy.

OUTFLOW CONTROL

The left lobe of the liver (segments II and III) is now mobilized from the diaphragm by division of the left triangular ligament from its tip up to the lateral margin of the suprahepatic inferior vena cava (IVC) (see Fig. 2-18). The upper surfaces of the left and middle hepatic veins, or of their common trunk and of the suprahepatic IVC, are displayed (see Fig. 2-16) (Czerniak et al., 1993). In essence, the veins are cleared below the diaphragm, and their junction with the vena cava is displayed. The left lobe of the liver (segments II and III) is turned to the right (Fig. 4-3). The gastrohepatic ligament is fully divided, and the ligamentum venosum is identified. The ligamentum venosum is divided close to its entry into the left hepatic vein. This division opens up a triangular tunnel, the sides of which are the left hepatic vein anteriorly, the anterior surface of the vena cava posteriorly, and the upper surface of segment II inferiorly. This tunnel is developed carefully, and an instrument is passed beneath the left and middle hepatic veins to emerge anterior to the vena cava between the middle hepatic vein and the right hepatic vein (see Fig. 4-3).

Figure 4-3 Approach and dissection of the left and middle hepatic veins applicable to left hepatectomy and extended left hepatectomy. A, The left lobe of the liver (segments II and III) is completely mobilized from the diaphragm and turned to the right. The gastrohepatic ligament is divided, and the line of the ligamentum venosum is exposed. B, The ligamentum venosum is divided. This maneuver allows exposure of the window between the vena cava and the left hepatic vein. With dissection in this space, it is possible to dissect free the left and middle hepatic veins separately or together (arrows). The left and middle hepatic veins are clamped, divided, and oversewn or divided using the Endo-GIA vascular stapler.

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