By analogy to the lung, the two divisions of the liver are best called the right liver and the left liver; thus “right hepatectomy” and “left hepatectomy” are the semantically appropriate terms for the removal of those parts of the liver.

Any one of the eight anatomical segments can be removed individually (by “segmentectomy”). The “surgical” segments of the liver are agglomeration of anatomical segments; Thus “surgical” segments might preferably be called “sectors”.

Ronald A. Malt. N.Engl.J.Medic. 1985

Glisson’s Capsule and Hepatic Trinity

Glisson’s capsule condenses around the hepatic trinity structures and surrounds them as they enter the liver substance. Thus each bile duct, hepatic artery and portal vein unit is surrounded by a fibrous sheath which is called by Couinaud the “Valoean sheath”

Any variations in the branching of the sectorial and segmental pedicles occur within the Glissonian sheath and a sheath contains only the elements supplying the parenchyma entered by this sheath. The supra hilar control of the trinity unit which supplies the part of the liver to be resected delineates the precise boundaries for the resection.

A. The Intrafascial or Hilar Approach 1952 (Lortat-Jacob)

1. Extrahepatic approach of hepatic pedicle

Ligation and elective division

- Artery

- Portal vein

- Biliary duct

However many anatomical variations

Useless in segmental resections

2. Extrahepatic approach of hepatic vein

B. The Extrafascial Approach B. The Extrafascial Approach 1957 (Couinaud)1957 (Couinaud)

The whole sheath is dissected directly

- either by a small incision on the inferior surface of the liver (Galperine)

- or with detachment of the hilar plate (Lazorthes)

These approaches are limited

C. The Extrafascial and C. The Extrafascial and Transfissural ApproachTransfissural Approach

1. Anterior transfissural approach through the main fissure (Couinaud 1957, Ton That Tung 1979)

2. Posterior transfissural approach through the dorsal fissure (personal technique 1992)

Posterior approach1. First method

• Anterior and posterior incisions to the right hepatic pedicle

2. Second method

• Taking down the hilar plate

• Posterior incision behind the hepatic pedicle

Right hepatic pedicle

Right medial pedicle

Posterior Approach3. Third method

Anterior, right and posterior incisions around the hepatic pedicle

Right hepatic pedicleRight medial pedicle

Right lateral pedicle

4. Fourth method

Anterior, right and posterior incisions. Incision on segment III behind the left hepatic pedicle

Superficialization of all left and right Glissonian sheaths

Controversies IControversies I

1. All techniques of isolation of Glissonian pedicles are “suprahilar”

- extrahepatic (or intraglissonian)

- extraglissonian

- transfissural

anterior

posterior

Controversies IIControversies II

2. The 3 approaches of glissonian pedicles were described by Couinaud in 1957 (Le Foie`: etudes anatomiques et chirurgicales)

Controversies IIIControversies III

3. Takasaki (1985)Extraglissonian approach by “blind” dissection

GalperinePeripheral hepatic incision

Lazorthes (1993)Detachment of the hilar plate

Launois and Jamieson (1992)Opening of dorsal fissure

Controversies IVControversies IV

4. The posterior approach should be called ….

“ superficialisation of glissonian pedicles”

H. BismuthPersonal Communication

Indications for Posterior Approach

1. Technical

2. Oncological

Technical Indications of Posterior Approach

1. Right hepatectomy

2. Right & left extended hepatectomies

3. Right segmentectomies

4. Post cholecystectomy strictures

5. Intrahepatic lithiasis

Segmentectomies of the Right Liver

1. Definition of the right lateral fissure

2. Segmentectomy V & VIII (right medial sectoriectomy)

3. Segmentectomy V

4. Segmentectomy VIII

5. Segmentectomy VII & VII (right lateral sectoriectomy)

6. Segmentectomy VI

7. Segmentectomy VII

One Contraindication to the Posterior Approach:

Involvement of the Glissonian confluence

Segmentectomy of the Caudate lobe (Segment I)

• Excision of segment I alone

• Excision of segment I and IV

• Excision of segment I and left hepatectomy

• Excision of segment I and right hepatectomy

Oncological Indications for the Posterior Approach

1. Klatskin tumour

2. Primary liver tumours

3. Secondary liver tumours

Klatskin Tumour1. Opening of the dorsal fissure

2. Superficialization of intrahepatic Glissonian sheaths

3. Assessment of extension

- To the right duct

- To the left duct

- To the liver parenchyma

4. Intrahepatic cholangiography

5. Tumour resection extended to the Glissonian sheaths

6. Resection of the caudate lobe

7. Palliative tumour resection

8. Bilateral palliative bypass (segment III & V)

Liver Metastases

• Ideal procedure: segmentectomy

- Large clear margin

- Possible in cases of multiple, bilobar metastases

- Allows repeat hepatectomies

Primary Liver cancer

• In non-cirrhotic liver

2 objectives:

1) Initial ligation of the vascular pedicle (avoiding dissemination of neoplastic cells.

2) Large clear margin.

• In cirrhotic liver

A third objective:

3) Saving of liver parenchyma, but difficulty of

dissecting liver parenchyma.

Liver ResectionsLiver Resections

Conclusions I

1. Posterior approach of hepatic hilus is a transfissural approach through the dorsal fissure between segment IV (and VIII) and I (and IX) in the plane of the Glissonian confluence sheaths

2. The main technical indications are:

- Right (extended) hepatectomy

- Left extended hepatectomy

- Segmentectomies of the right liver

Conclusions II

3. The oncological indications are mainly:

- Klatskin tumour (mandatory)

- Primary and secondary liver cancer

4. The progress of the liver operative techniques improved the long term survival.