Hepato-Biliary-

Pancreatic Surgery
and Liver
Transplantation

A Comprehensive Guide,
with Video Clips
Hee Chul Yu
Editor
Hepato-Biliary-Pancreatic Surgery
and Liver Transplantation
Hee Chul Yu
Editor

Hepato-Biliary-­
Pancreatic Surgery
and Liver
Transplantation
A Comprehensive Guide,
with Video Clips
Editor
Hee Chul Yu
Chairman of the Korean Association of HBP Surgery
Jeonbuk National University Medical School
Jeonbuk National University Hospital
Jeonju, Korea (Republic of)

ISBN 978-981-16-1995-3    ISBN 978-981-16-1996-0 (eBook)

https://doi.org/10.1007/978-981-16-1996-0

© Springer Nature Singapore Pte Ltd. 2023

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Preface

Established in 1992, the Korean Association of Hepato-Biliary-Pancreatic

Surgery (KAHBPS) has a history of more than 20 years and improved its
status in terms of quality, as well as quantitative growth, including liver trans-
plantation, beyond Asia to the global level.
Hepatobiliary and pancreatic (HBP) surgery requires a lot of expertise.
Safe surgical practices can minimize complications after surgery and are
directly related to the patient’s prognosis. In particular, KAHBPS began to
contemplate the need for surgical guidelines that could be referenced by
young HBP surgeons who were currently developing their skills. Therefore,
we worked for two years with about 50 HBP experts in Korea and completed
the Korean version of the Hepatobiliary and Pancreatic Surgery Master col-
lection in 2015.
Currently, many Korean HBP surgeons are leading global research mem-
bers in international research and academic fields. Therefore, since KAHBPS
felt the responsibility not only to focus on the education of Korean surgeons
but to provide extensive help to young HBP surgeons across the world and
beyond the language barrier, we decided to publish an English version.
The contents of the book were divided into three parts: the liver, biliary
tract, and pancreas. We tried to write the surgical techniques as simply and
concisely as possible and attached pictures and videos for easy understand-
ing. In particular, as the worlds’ leading group in the field of liver transplanta-
tion, we added relatively more content on transplantation.
We would like to thank the authors for their hard work in writing from
time to time while performing long hours of surgery and medical practice. We
remain grateful to the planning director, the committee members, and the
publishers who put their entire hearts and souls into publishing a beautiful
book with meticulous effort.
We trust that this book will contribute to improving the surgical skills of
HBP surgeons and hope it will be widely used as a valuable material in the
training process of young surgeons. Based on this book, we hope that stan-
dard surgical procedures will be established in the field of HBP surgery and
progressively developed worldwide.

Jeonju, Republic of Korea Hee Chul Yu

v
Contents

Part I Operative Technique of Hepatectomy

1 
Use of Intraoperative Ultrasonography ����������������������������������������   3
Il-Young Park
2 The Techniques and Instruments for Minimizing
Bleeding During Parenchymal Dissection��������������������������������������   7
Dong-Sik Kim
3 
The Safe Application of Hanging Maneuver �������������������������������� 13
Seoung Hoon Kim
4 Left Hemihepatectomy�������������������������������������������������������������������� 21
Jin Sub Choi
5 Right Hemihepatectomy������������������������������������������������������������������ 27
Yoon Jin Hwang and Hyung Jun Kwon
6 Central Bisectionectomy������������������������������������������������������������������ 33
Kyung Sik Kim
7 Left Lateral Sectionectomy ������������������������������������������������������������ 39
Tae-Jin Song
8 Right Anterior Sectionectomy�������������������������������������������������������� 43
Koo Jeong Kang and Keun Soo Ahn
9 Right Posterior Sectionectomy�������������������������������������������������������� 53
Yang-Seok Koh
10 S4 Segmentectomy With or Without Resection
of Ventral Area of Right Anterior Section������������������������������������� 57
Yang Won Nah
11  & S6 Segmentectomy������������������������������������������������������������������ 63
S5
Soon-Chan Hong and Chi-Young Jeong
12  & S8 Segmentectomy������������������������������������������������������������������ 65
S7
Hee Jung Wang and Sung Yeon Hong
13 Laparoscopic Left Hemihepatectomy�������������������������������������������� 71
Ki-Hun Kim and Hwui-Dong Cho

vii
viii Contents

14 Laparoscopic
 Left Lateral Sectionectomy ������������������������������������ 77
In Seok Choi and Ju Ik Moon
15 Laparoscopic Right Hemihepatectomy������������������������������������������ 81
Ho-Seong Han and Jai Young Cho

Part II Deceased Donor Liver Transplantation

16 Liver
 Procurement in a Deceased Donor �������������������������������������� 87
Hee Chul Yu and Jae Do Yang
17 Recipient Hepatectomy Without Venovenous Bypass������������������ 97
Jin Sub Choi
18 Recipient
 Hepatectomy with Venovenous Bypass ������������������������ 103
Gi-Won Song
19 Implantation
 of the Deceased Donor Liver Graft ������������������������ 109
Young Kyoung You

Part III Living Donor Liver Transplantation

20 Donor
 Right or Extended Right Hemihepatectomy �������������������� 115
Jae-Won Joh and Gyu-seong Choi
21 Donor Left Hemihepatectomy�������������������������������������������������������� 121
Kyung-Suk Suh and Suk Kyun Hong
22 Living
 Donor Liver Graft Back-­Table Procedure������������������������ 127
Choon Hyuck David Kwon and Gyu-seong Choi
23 Middle
 Hepatic Vein Reconstruction of Right Liver Graft���������� 131
Dong-Sik Kim
24 Recipient Total Hepatectomy���������������������������������������������������������� 135
Kwang-Woong Lee and Jaehong Jeong
25 Reconstruction
 of Hepatic Vein and Portal Vein �������������������������� 141
Deok-Bog Moon and Sung-Gyu Lee
26 Hepatic Artery Anastomosis������������������������������������������������������������ 159
Chul-Soo Ahn
27 Biliary Reconstruction�������������������������������������������������������������������� 163
Bong-Wan Kim

Part IV Cholecystectomy

28 Laparoscopic
 Cholecystectomy (3–4 Ports Method)�������������������� 169
Sang Mok Lee
29 L
 aparoscopic Single-Site Cholecystectomy
(Single Port Method)������������������������������������������������������������������������ 177
Dong-Hoon Shin
Contents ix

30 
Laparoscopic Surgery for Gallbladder Polyps
and Early-­Stage Gallbladder Cancer�������������������������������������������� 181
Woo-Jung Lee and Myung Jae Jung
31 
Extended Cholecystectomy (Wedge Resection)���������������������������� 187
Kim Wan-Joon and Kim Wan-Bae
32 Extended Cholecystectomy (Including Segment
IVb and V Resection) ���������������������������������������������������������������������� 191
Sang-Jae Park

Part V Resection of Choledochal Cyst

33 
Open Resection of Chledochal Cyst ���������������������������������������������� 199
Kuk Hwan Kwon and Jin Ho Lee
34 
Laparoscopic and Robotic Excision of Choledochal Cyst������������ 207
Jin-Young Jang and Jae Seung Kang

Part VI Hilar Cholangiocarcinoma

35 
Extended Right Hepatectomy and Caudate Lobectomy�������������� 217
Shin Hwang

Part VII Extrahepatic Bile Duct Cancer

36 Bile Duct Resection�������������������������������������������������������������������������� 231

Joo Seop Kim
37 Pancreatico-duodenectomy ������������������������������������������������������������ 235
Sang Geol Kim and Hyung Jun Kwon
38 Hepatopancreatoduodenectomy ���������������������������������������������������� 245
Shin Hwang

Part VIII Operative Technique of Pancreatectomy

39 Pylorus-Preserving Pancreaticoduodenectomy���������������������������� 253

Dong Sup Yoon and Joon Seong Park
40 Radical Antegrade Modular Pancreatosplenectomy
(RAMPS)������������������������������������������������������������������������������������������ 263
Sung Su Yun and Dong-Shik Lee
41 Spleen-Preserving Distal Pancreatectomy ������������������������������������ 267
Yong Hoon Kim
42 Laparoscopic Pancreaticoduodenectomy�������������������������������������� 273
Song Cheol Kim and Ki Byung Song
43 Laparoscopic Distal Pancreatectomy �������������������������������������������� 279
Chang Moo Kang
x Contents

44 Laparoscopic Central Pancreatectomy������������������������������������������ 295

Yoo-Seok Yoon
45 T
 ransduodenal Ampullectomy of Ampullary Adenoma�������������� 301
Jinseok Heo and Wooil Kwon
46 Essential
 Tips for Pancreatic and Duodenal Surgery:
Vessel Resection�������������������������������������������������������������������������������� 307
Song Cheol Kim and Dae Wook Hwang
47 E
 ssential Tips for Reconstruction After
Pancreaticoduodenectomy�������������������������������������������������������������� 311
Sung-Sik Han, Dong Eun Park, Koo Jeong Kang,
and Young Kyoung You
List of Videos

Video 1.1 Intraoperative liver ultrasonography (Il-Young Park)

Video 1.2 Case. Intraoperative ultrasound in HCC (Il-Young Park)
Video 1.3 Case. Intraoperative ultrasound in metastatic tumor
(Il-Young Park)
Video 1.4 Case. Safety margin during liver resection (Il-Young Park)
Video 1.5 Case. Radiofrequency ablation (RFA) (Il-Young Park)
Video 1.6 Laparoscopic ultrasound (Il-Young Park)
Video 3.1 The safe use of hanging maneuver (central
bisectionectomy) (Seoung Hoon Kim)
Video 4.1 Left hemihepatectomy (intrahepatic duct stone)
(Jin Sub Choi)
Video 5.1 Right hemihepatectomy (Yoon Jin Hwang)
Video 6.1 Central bisectionectomy (Kyung Sik Kim)
Video 7.1 Left lateral sectionectomy (Tae-Jin Song)
Video 8.1 Right anterior sectionectomy (Koo Jeong Kang)
Video 9.1 Right posterior sectionectomy (preserving RHV)
(Chol Kyoon Cho)
Video 9.2 Right posterior sectionectomy sacrificing RHV
(Chol Kyoon Cho)
Video 10.1 Resection of segment 4 and ventral portion of anterior
section (Yang Won Nah)
Video 11.1 Segmentectomy 5-6 (Chiyoung Jeong)
Video 12.1 Segmentectomy 8 (classic anatomical resection)
(Hee Jung Wang)
Video 12.2 Segmentectomy 8 (Makuuchi’s blue dye staining method)
(Hee Jung Wang)
Video 12.3 Segmentectomy 8 (Takasaki’s method) (Hee Jung Wang)
Video 13.1 Laparoscopic left hepatectomy (Ki-Hun Kim)
Video 14.1 Laparoscopic left lateral sectionectomy (In Seok Choi)
Video 15.1 Laparoscopic right hemihepatectomy (Ho-Seong Han)
Video 16.1 Modified rapid-en-loc liver recovery in deceased donor
(Hee Chul Yu)
Video 17.1 Recipient hepatectomy in DDLT, no use of venovenous
bypass (Jin Sub Choi)
Video 20.1 Living donor right or extended right hemihepatectomy
(Jae-Won Joh)
Video 21.1 Living donor left hemihepatectomy (Kyung-Suk Suh)

xi
xii List of Videos

Video 22.1 Bench procedure of deceased donor graft

(Choon Hyuck Kwon)
Video 22.2 Bench procedure of living donor graft
(Choon Hyuck Kwon)
Video 23.1 Reconstruction of middle hepatic vein using cryopreserved
iliac vein—optimizing outflow enabling single anastomosis-
(Dong-­Sik Kim)
Video 24.1 Recipient hepatectomy in DDLT, high hilar dissection (case 1)
(Kwang-Woong Lee)
Video 24.2 Recipient hepatectomy in DDLT, high hilar dissection (case 2)
(Kwang-Woong Lee)
Video 24.3 Recipient hepatectomy in DDLT, high hilar dissection (case 3)
(Kwang-Woong Lee)
Video 24.4 Eversion thrombectomy of portal vein thrombus
(Chong Woo Chu)
Video 24.5 Recipient hepatectomy (Chong Woo Chu)
Video 27.1 Duct-to-duct anastomosis with external drainage in LDLT
using RL graft (Bong-Wan Kim)
Video 28.1 Laparoscopic cholecystectomy (4 ports) (Sang Mok Lee)
Video 28.2 Laparoscopic cholecystectomy (2 mm instruments) (Sang
Mok Lee)
Video 29.1 Single incision laparoscopic cholecystectomy
(Dong-Hoon Shin)
Video 30.1 Hybrid cholecystectomy with radical LN dissection
(#12, 7, 8, 9.16) (Woo-Jung Lee)
Video 31.1 Extended cholecystectomy (Kim Wan-Joon)
Video 33.1 Excision of choledochal cyst (Kuk Hwan Kwon)
Video 34.1 Laparoscopic excision of choledochal cyst (Jin-Young Jang)
Video 35.1 Extended right hepatectomy with caudate lobectomy
(Sun-Whe Kim)
Video 35.2 Hepaticopancreatoduodenectomy (extended right
hepatectomy) (Dong Wook Choi)
Video 37.1 Pancreaticoduodenectomy (for the extrahepatic
cholangiocarcinoma) (Sang Geol Kim)
Video 39.1 Pylorus preserving pancreaticoduodenectomy (for the
pancreatic cancer) (1) (Dong Sup Yoon)
Video 39.2 Pylorus preserving pancreaticoduodenectomy (for the
pancreatic cancer) (2) (Jin-Young Jang)
Video 40.1 Distal pancreatectomy (RAMPS) (Hong-Jin KIM)
Video 42.1 Laparoscopic pancreaticoduodenectomy (Song Cheol Kim)
Video 43.1 Laparoscopic distal pancreatectomy (Chang Moo Kang)
Video 44.1 Laparoscopic central pancreatectomy (Yoo-Soek Yoon)
Video 45.1 Transduodenal ampullectomy (jinseok heo)
Video 46.1 Portal vein resection and reconstruction during pancreatico-
duodenectomy (Song Cheol Kim, Dae Wook Hwang)
Video 47.1 Pancreaticojejunostomy (duct-to-mucosa) (Seung ik Ahn)
Video 47.2 Pancreaticojejunostomy (dunking method)
(Hyung Chul Kim)
List of Videos xiii

Video 47.3 External drainage of pancreatic duct (Dong Eun Park)

Video 47.4 Pancreaticojejunostomy with transhepatic external drainage
(Koo Jeong Kang)
Video 47.5 Pancreaticogastrostomy with external drainage
(You Young Kyoung)
 Part I
Operative Technique of Hepatectomy
 Use of Intraoperative
Ultrasonography 1
Il-Young Park

Abstract atectomy and, thereafter, continued to improve

following the development of B-mode ultra-
Intraoperative ultrasonography is an important
sound. The detection rate of liver mass with
technique to find, resect, and treat lesions.
IOUS is superior to that of CT, MRI, and even
Laparoscopic ultrasound is a useful tool for
laparotomy. IOUS can detect lesions as small as
laparoscopic surgery. Hepato-pancreato-­
1 mm stones and 3–5 mm masses [1]. Thus, HPB
biliary surgeons have to be familiar with ultra-
surgeons greatly benefit from IOUS by integrat-
sonography during operations.
ing their anatomical knowledge with ultrasound
techniques.
Keywords
IOUS consists of a body and probes of differ-
Intraoperative ultrasonography ent types. The ultrasound frequencies used in
Laparoscopic ultrasound probes range from 5 MHz to 10 MHz, and
7.5 MHz probe is most commonly used. These
Ultrasound is an essential technique for surgeons. probes can penetrate around 6–10 cm in depth.
Particularly, hepato-pancreato-biliary (HPB) sur- IOUS probes include linear, T-shape, I-shape,
geons should be familiar with ultrasound when convex, and sector-type probes, similar to general
diagnosing, treating, or operating a patient. This ultrasound probes. When examining the anatomi-
chapter will focus on intraoperative ultrasound cal structures, methods such as sliding, rotating,
techniques, with the intent to allow HPB sur- tilting, and rocking are used in IOUS, similar to
geons to perform ultrasound more easily during the techniques used in abdominal ultrasound.
surgery. IOUS not only enables surgeons to screen for dis-
Intraoperative ultrasonography (IOUS) was eases involving liver, gallbladder, and pancreas,
first performed in 1979 by Makuuchi during hep- but also diseases involving retroperitoneal space
consisting of kidney, adrenal gland, spleen, and
Supplementary Information The online version con- aorta.
tains supplementary material available at https://doi. Lesions of the liver are easily detected and
org/10.1007/978-­981-­16-­1996-­0_1. compared with surrounding structures with ultra-
sound. The division of the anatomical structure of
I.-Y. Park (*) liver is based on hepatic vein according to the
Department of Surgery, Bucheon St. Mary’s Hospital, Couinaud classification. In addition to the normal
The Catholic University of Korea College of anatomical structures, HBP surgeons are advised
Medicine, Bucheon, South Korea to be familiar with different variations of the
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 3

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_1
4 I.-Y. Park

HBP structures [2–4]. When performing IOUS,

T-type probes are most commonly used; the
probe is placed between the index and middle
­fingers during the examination of liver surface.
When examining the liver, the left and the right
lobes should be scanned transversely and then
longitudinally. Next, the probe should be slid,
rotated, tilted, and rocked in all four ways in
order to identify the anatomical structures of
liver. Finally, the bottom of liver should also be
scanned for any existing lesions (Fig. 1.1, Video
1.1). Images using stand-off method can be
obtained by pressing the probe against the liver
surface or by placing saline solution in between
the probe and the skin (Fig. 1.2). Common benign Fig. 1.2 Standoff scanning
lesions of the liver include low-echogenic liver
cyst and high-echogenic hemangioma; malignant to perform ultrasound-guided radio-frequency
lesions of liver include hepatocellular carcinoma ablation (RFA) (Fig. 1.3, Video 1.4).
and metastatic cancer with low-echogenic halo Compared to intraoperative cholangiography,
surrounding the mass. IOUS can be used to detect biliary stones more
In addition to localization of liver lesions, easily and quickly, owing to its superior detection
IOUS allows the surgeon to constantly evaluate rate. Bile duct is visualized by scanning the cystic
whether the lesion is accurately resected during duct and common bile duct transversely and lon-
surgery. Further, IOUS is used to inject the dye gitudinally. However, in cases where bile duct
into the portal vein, after which the liver is ana- cannot be reached directly, a stand-off technique
tomically resected along the dye-stained area. can be used: saline is poured in between the liver
Even during liver transplantation, IOUS is neces- and the peritoneum, and the probe is placed
sary for identifying the blood flow before and within the saline during IOUS (the shape of bile
after the transplantation. In cases where the duct, portal vein, and hepatic artery during ultra-
hepatic lesions cannot be resected, IOUS is used sound resembles the face of Mickey Mouse). The
color Doppler allows a surgeon to easily
­distinguish bile ducts from arteries, and biliary
stones are found along with a posterior
shadowing.
Before performing IOUS, the pancreas should
first be scanned transversely and longitudinally,
followed by sliding, rocking, rotating, and tilting
to identify the lesion and the nearby structures
(Fig. 1.4). In order to better visualize the pancre-
atic head, the Kocher maneuver can be performed
before IOUS. IOUS is useful in detecting acute
pancreatitis, pancreatic pseudocysts, pancreatic
stones and pancreatic duct dilation in chronic pan-
creatitis, benign pancreatic tumors such as insuli-
noma, and pancreatic cancer. Splenic vein and
pancreatic duct can be visualized by directly
applying the probe onto the pancreas. In cases
Fig. 1.1 Intraoperative liver scanning where direct contact is difficult, the stand-off tech-
1 Use of Intraoperative Ultrasonography 5

Fig. 1.5 Laparoscopic ultrasound scan of the liver (a)

Fig. 1.3 Radio-frequency ablation method umbilical port, (b) right lower abdominal port, (c) left
abdominal port

but is distinct in that its distal end is equipped

with a sector, rigid, flexible linear array probe of
4 cm in size, which bends to a maximum of 90°
in most cases. When performing LUS, the device
is inserted into the umbilical port or upper
abdominal quadrant port via 10 mm trocar, and
the liver is examined longitudinally and trans-
versely (Fig. 1.5, Video 1.5). Similarly, the com-
mon bile duct is scanned longitudinally and
transversely to visualize portal vein and hepatic
artery, which are the landmarks that allow the
surgeon to detect bile duct and lesions such as
biliary stones and cysts. In case of pancreas, the
LUS probe is inserted into the upper abdominal
or umbilical port. Laparoscopic ultrasonography
Fig. 1.4 Intraoperative pancreatic scanning is either performed via stomach after removing
the gastric gas or on the pancreas directly
nique can be performed by pouring saline into the (Fig. 1.6). Performing LUS during laparoscopic
lesser sac. In patients with chronic pancreatitis, surgery not only allows the surgeon to obtain
IOUS facilitates surgery by allowing the surgeons intraoperative images and localize the lesion, but
to locate pancreatic duct and pancreatic stones. also enables the surgeon to perform ultrasound-
With increasing number of laparoscopic oper- guided biopsies and provide treatments such as
ations, direct palpation of internal organs during RFA.
laparoscopic surgery has become less accessible. To summarize, IOUS plays an important role
To overcome these shortcomings, laparoscopic in HPB surgery. It is highly sensitive for detect-
ultrasound (LUS) can be inserted into the abdo- ing HPB lesions and guiding biopsies, resections,
men via the port to visualize anatomical struc- and ablation therapies. Thus, HPB surgeons
tures, find lesions, and perform biopsy or RFA should become familiar with IOUS techniques so
[1, 5]. LUS is similar to other ultrasound devices, as to explore all its advantages during surgery.
6 I.-Y. Park

c References
1. Benson MD, Gandhi MR. Ultrasound of the
hepatobiliary-pancreatic system. World J Surg.
2000;24(2):166–70.
2. Kruskal JB, Kane RA. Intraoperative US of the liver:
techniques and clinical applications. Radiographics.
2006;26(4):1067–84.
3. Patel NA, Roh MS. Utility of intraoperative ultra-
b sound. Surg Clin North Am. 2004;84(2):513–24.
4. Schrope B. Surgical and interventional ultrasound.
McGraw-Hill Education; 2014.
5. Machi J, et al. Technique of laparoscopic ultrasound
examination of the liver and pancreas. Surg Endosc.
1996;10(6):684–9.
a

Fig. 1.6 Laparoscopic ultrasound scan of the pancreas

(a) umbilical port, (b) right abdominal port, (c) left
abdominal port
 The Techniques and Instruments
for Minimizing Bleeding During 2
Parenchymal Dissection

Dong-Sik Kim

Abstract ering the central venous pressure, and minimiz-

ing the time required for transection of the
Because the liver is an organ with high-blood
parenchyma.
flow, liver resection is accompanied by sig-
nificant bleeding unless adequate surgical
techniques and appropriate instruments are
2.1 Methods to Control
not prepared. In this chapter, commonly used
Blood Flow
surgical techniques and instruments to mini-
mize bleeding during liver resection are intro-
Although it is a natural process to occlude the
duced. Understanding and application of
blood supply to the site for partial resection of
appropriate techniques and instruments are
the liver, unexpected bleeding may occur fre-
essential components of safe and efficient
quently due to abundant blood flow in the liver
surgery.
during the process of parenchymal transection.
Because the liver is relatively resistant to isch-
Keywords
emia, blood flow to the liver can be frequently
Inflow control · Pringle method · Total controlled to reduce bleeding during transection
vascular exclusion · Liver resection of the parenchyma.
Parenchymal transection · CUSA

2.1.1 Inflow Control, Pringle

Methods routinely used to reduce bleeding dur- Maneuver
ing hepatectomy include blocking of blood
inflow to the liver to reduce bleeding from the It is the most commonly used and convenient
portal vein or hepatic artery, placing the liver method to block blood flow to the liver using a
higher than natural position after mobilization to simple instrument across hepatoduodenal liga-
reduce the bleeding from the hepatic vein, low- ment, which contains the common hepatic artery
and the main portal vein (Fig. 2.1).
First, the transparent portion in the lesser omen-
D.-S. Kim (*) tum on the left side of the hepatoduodenal ligament
Division of HBP Surgery and Liver Transplantation, should be identified and opened via electrocautery.
Department of Surgery, Korea University College of The hepatoduodenal ligament can be easily
Medicine, Seoul, South Korea wrapped and evaluated using the left-­hand middle
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 7

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_2
8 D.-S. Kim

tape separately on the right and left sides after

dissection of hilar plate. In this case, only half of
the liver becomes ischemic and intestinal conges-
tion can be avoided.

2.1.2 Total Vascular Exclusion

In contrast to the Pringle maneuver in which only

the blood flow to the liver is blocked, total vascu-
lar exclusion is a method used to simultaneously
block the hepatic vein or both the upper and
lower vena cava to block the reflux through the
hepatic vein in addition to blocking the inflow.
Fig. 2.1 When the hepatoduodenal ligament is wound
Theoretically, reduction in bleeding may be more
with a nylon tape and the Rummel catheter is inserted, and
the Rummel catheter is tightened using a Kelley clamp, effective, but in practice, it can be applied only
blood flow to the liver can be blocked after the liver is completely mobilized or the
hepatic veins are isolated, which takes more time
and effort. Compared with inflow control, addi-
finger through the foramen of Winslow. A nylon tional benefits are not clear for conventional liver
tape with a Rummel catheter or an angled vascular resections and there is a potential risk of hemody-
clamp covered with rubber can be used to occlude namic instability. However, it is used selectively
blood inflow to the liver. In general, intermittent when surgery is performed in the proximity of
inflow occlusion is frequently used by alternating the hepatic veins or when resection or reconstruc-
15 min of blockade with 5 min of release. tion of the cava is required.
Parenchymal transection can be performed during If the duration of total vascular exclusion is
15 min of inflow occlusion. However, in some expected to be prolonged, perfusion of a cold
cases, a continuous blockade is inevitable. It should organ preservation solution such as histidine–
be noted that prolonged blockage of the portal vein tryptophan–ketoglutarate (HTK) solution may be
can lead to intestinal congestion. considered through the portal vein to minimize
The duration of safe inflow occlusion has yet ischemic damage to the liver (total vascular
to be determined, but it is clear that the higher the exclusion with hypothermic perfusion). In this
liver dysfunction, the shorter is the tolerance case, to prevent congestion of the intestine and
limit [1]. If the structures of the hepatic hilum are help hemodynamic stability, it is common to
individually dissected, the hepatic artery and the bypass blood circulation in the portal vein and
portal vein may be separately blocked using a the inferior vena cava to superior vena cava using
Bull-dog clamp. Even in cases of adhesion a centrifugal pump (Fig. 2.2).
involving the hepatic hilum or in relatively sim- In the case of a normal liver, it is known that
ple cases of resection, it is important to always this method can be used for up to 2 h, and it is
prepare for the inflow control to reduce bleeding reported that it has advantages in hemodynamics
and prepare for unexpected situations. during surgery or renal function after surgery
If it is possible to achieve the desired purpose compared to simple total vascular exclusion [2].
by blocking bloodstream only on the right or left In alternative cases, a method of excision of
side at a time due to tumor location or in cases of the inferior vena cava while bypassing hepatic
central bisectionectomy, it is also possible to use venous blood flow extracorporeally, rather than
hemihepatic inflow occlusion, via hanging nylon portal blood flow, has also been reported [3].
2 The Techniques and Instruments for Minimizing Bleeding During Parenchymal Dissection 9

studies with other recently developed instruments

reported that the superiority of the latest instru-
ments could not be observed in conventional
hepatic resection [4].
First, the cutting line of the liver surface is
marked with electrocautery. At this time, it is
important to cauterize the capsules on the liver
surface completely, so that they can be easily
separated by the device. To facilitate the cutting
of the parenchyma and to control the cutting
direction, a suture-tie at the edge is placed to pull
the liver to both sides of the cutting surface and
evenly about 45° each with an assistant. In the
Fig. 2.2 Total vascular exclusion with veno-venous beginning, it is better to start with a small bite of
bypass using a centrifugal pump the liver that is crushed at a time and determine
the tendency to bleed from the cut surface. When
2.2 Methods and Instruments breaking the parenchyma, only the tubular struc-
for Parenchymal Transection tures remain, which are ligated using a clip or tie
and then cut.
Resection of the liver parenchyma entails crush- Very small blood vessels or connective tissues
ing the parenchymal tissues while effectively resulting from liver fibrosis can also be cut via elec-
ligating and resecting the blood vessels or biliary trocautery. In some cases, the first assistant may
ducts inside the liver, which are distributed along save time by cauterizing small blood vessels with an
the desired resection line. To this end, instruments instrument such as a bipolar coagulator. When the
(Fig. 2.3) using various mechanisms of operation vasculature is not clear due to crushed parenchymal
have been developed. However, an important tissues, it can be seen more clearly by squirting
principle to always keep in mind, regardless of the from a spoid. At this time, placing the capped suc-
instrument used, is that there must be adequate tion in the lower or behind of the right lobe of the
physical traction on both the sides of the cut sur- liver helps to keep the surgical field clear.
face so that the transection is facilitated by effec-
tive functioning of the instruments. The surgeon
and the first assistant should be careful to main- 2.2.2 Cavitron Ultrasonic Surgical
tain this traction effectively throughout the entire Aspirator (CUSA)
process so that the transection can progress
quickly and effectively. To this end, sutures can be This is a device that pulverizes the parenchyma
placed on both sides of the transection surface to while leaving only the vasculature of the intersti-
pull the parenchyma (Fig. 2.4), or the cut surface tial tissue using ultrasonic vibration, and at the
is spread to both sides using a forceps or mallea- same time aspirates and removes the crushed tis-
ble retractor. In some cases, the transection sur- sue. It is most widely used in hepatectomies for
face may be spread using the left hand of the live donors or hilar cholangiocarcinoma.
operator or even gravity based on liver weight. Depending on the model, the electrocautery is
integrally combined to facilitate the use. Because
the physical properties of the liver may vary
2.2.1 Clamp Crushing Method depending on the presence or absence of fatty
liver or the degree of fibrosis, the intensity of
It is the oldest, but the most basic and universally ultrasonic vibration needs to be adjusted.
used method. Common instruments used are While moving the tip of the instrument per-
Kelly clamp and Pean hemostat. Comparative pendicular to the cut surface, the tissue is crushed
10 D.-S. Kim

a b

c d

e f

g h

Fig. 2.3 Instruments for parenchymal transection using (a) Kelley Clamp, (b) CUSA (Cavitron Ultrasonic Surgical
Aspirator), (c) Water-jet, (d) Harmonic Scalpel, (e) Ligasure, (f) Tissue-Link, (g) Habib, (h) Stapler

by contact with the parenchyma and the remain- 2.2.3 Water Jet
ing tubular structures are cauterized or ligated
using clips or ties. If Glisson pedicles appear, It is a mechanism that destroys the parenchyma
they should be ligated, taking care not to destroy and leaves only the tubular structures using a
the capsule of pedicle by the tip of the instru- high-pressure stream of water, which acts similar
ment. If the hepatic vein is exposed to the cutting to CUSA.
surface, bleeding should be avoided because the
branch is cut off due to excessive traction.
2 The Techniques and Instruments for Minimizing Bleeding During Parenchymal Dissection 11

been heated by high-frequency energy, on the

ablation surface.

2.2.7 Habib

This is a method of solidifying the liver tissue of

the cut surface using microwave energy and then
cutting with scissors and clips. The liver can be
Fig. 2.4 Traction of the liver during parenchymal tran-
resected relatively quick, but care must be taken
section. Suture-tie using thick sutures on both sides of the due to the risk of unexpected damage when
liver parenchyma. It can be reinforced using a pledget to important vasculature exists on the coagulated
avoid tearing of the liver from traction. The traction forces cut surface. In addition, the extent of coagulation
from the operator and the assistant should be balanced so
that they are not biased on either side
should be predicted adequately so that only the
site to be excised is coagulated.

2.2.4 Harmonic Scalpel

2.2.8 Stapler
It is a device that cuts while cauterizing the
parenchyma using thermal energy generated by Staplers can be selectively used when rapid
ultrasonic vibration and is often used in laparo- resection is required in trauma patients with
scopic liver resection surgery. The harmonic scal- unstable hemodynamics or when the parenchy-
pel can easily proceed up to 1 cm from the surface mal thickness is thin, such as in the left lateral
of the liver, where few important vasculatures are section by passing the stapler blades along the
located, but care must be taken not to damage the expected resection plane and cutting the paren-
vasculature that requires ligation when proceed- chyma. Adequate knowledge about the blood
ing deeper. Therefore, do not cauterize large vessels and biliary tract structure inside the liver
amounts of tissue at a time, but proceed gradually can ensure safe use. Otherwise, it may cause
to determine if there are major structures to be severe bleeding or leakage of the bile. It is rec-
ligated. ommended to wait about 10 s after closing the
jaw before firing. Insufficient vascular seal is
suggested when the excessive parenchyma is
2.2.5 Ligasure included between the jaws. In most cases, only
the left or right Glisson or hepatic vein is selec-
Originally developed as a concept of the vessel-­ tively separated and cut using a stapler.
sealing device, it is a bipolar energy device that is
sometimes used for liver resection. It is used
­similar to the harmonic scalpel, and it is safer to References
ligate separately rather than to seal important
vasculature thermally. 1. Torzilli G, Procopio F, Donadon M, Del Fabbro D,
Cimino M, Montorsi M. Safety of intermittent Pringle
maneuver cumulative time exceeding 120 minutes in
liver resection: a further step in favor of the “radical but
2.2.6 Tissue-Link conservative” policy. Ann Surg. 2012;255(2):270–80.
2. Azoulay D, Eshkenazy R, Andreani P, Castaing D,
Adam R, Ichai P, et al. In situ hypothermic per-
The principle is to mechanically ablate using a fusion of the liver versus standard total vascular
hook at the end of the instrument after solidify- exclusion for complex liver resection. Ann Surg.
ing the tissue by dripping saline, which has 2005;241(2):277–85.
12 D.-S. Kim

3. Kim DS, Yu YD, Jung SW, Ji W, Suh SO. Extracorporeal 4. Rahbari NN, Koch M, Schmidt T, Motschall E,
hepatic venous bypass during en bloc resection of Bruckner T, Weidmann K, et al. Meta-analysis of the
right trisection, caudate lobe, and inferior vena cava: a clamp-crushing technique for transection of the paren-
novel technique to avoid hypothermic perfusion. J Am chyma in elective hepatic resection: back to where we
Coll Surg. 2013;216(5):e47–50. started? Ann Surg Oncol. 2009;16(3):630–9.
 The Safe Application of Hanging
Maneuver 3
Seoung Hoon Kim

Abstract 3.1 Liver Anatomy Based

The liver can be divided into three sections on Three Glisson’s Pedicles
depending on the area supplied by the right and Three Hepatic Veins
anterior, right posterior, and left Glissonian
pedicles. It can also be divided into three sec- Portal vein, hepatic artery, and bile duct, which
tions according to the area drained by the right, are encased in a sheath, constitute the Glissonian
middle, and left hepatic veins. A hanging tape pedicle, which is divided into the right and the
can be applied along the anteromedian surface left Glissonian pedicles at the liver hilum. The
of the retrohepatic inferior vena cava or the right Glissonian pedicle branches into the ante-
ligamentum venosum with its upper end rior and posterior Glissonian pedicles (Fig. 3.1).
among the three hepatic veins and its lower Accordingly, liver can be divided into three sec-
end among the three Glissonian pedicles. The tions that are supplied by the three Glissonian
advantages of the liver-hanging maneuver and pedicles, respectively. The liver can also be
the anatomic characteristics inherent to the divided into three sections that are drained by
liver enable hepatic surgeons to make safe and each of the three major hepatic veins: right
effective use of a hanging technique in a vari- hepatic vein (RHV), middle hepatic vein (MHV),
ety of anatomic liver resections. and left hepatic vein (LHV) (Fig. 3.2).
Variations such as anomalous branching of the
Keywords three Glissonian pedicles or the three major
hepatic veins can occur, sometimes accompanied
Hanging maneuver · Liver resection by large inferior hepatic veins.
Hepatectomy · Liver anatomy · Liver surgery The preoperative dynamic CT scan can be
used to elucidate the anatomy, to enable surgical
dissection of the three Glissonian pedicles or the
Supplementary Information The online version con- three major hepatic veins during operation.
tains supplementary material available at https://doi.
org/10.1007/978-­981-­16-­1996-­0_3.

S. H. Kim (*)
Department of Surgery, National Cancer Center,
Goyang-si, Gyeonggi-do, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 13

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_3
14 S. H. Kim

remaining liver, and maintain the transection

plane effectively without other auxiliary tech-
niques, so that the parenchyma can be safely
divided without compression of the remaining
liver. Glissonian approach using hanging maneu-
ver was also reported in various kinds of hepatec-
tomy in which the simple and effective technique
yielded good outcomes [2].
A single plane of transection yields two com-
plementary types of anatomic liver resection. For
example, right posterior sectionectomy with
RHV carries the same transection plane as left
trisectionectomy with the caudate lobe. All the
Fig. 3.1 Hilar dissection of three Glissonian pedicles.
The anterior, posterior, and left Glissonian pedicles are transection planes discussed in this article are
dissected and encircled by a sling, respectively longitudinal, parallel to, and oriented to the IVC
or the ligamentum venosum along which the tape
is located. The resected parenchyma has an
inverted pyramid shape.

3.3 Surgical Techniques

A J-shaped incision with or without a left exten-

sion is generally used to enter the abdomen,
depending on the specific circumstances. Large
tumors of the right liver, especially those lying
posteriorly and possibly involving the IVC, may
require extension via the right thoracoabdominal
approach. However, the upper midline incision
Fig. 3.2 Three hepatic veins at the suprahepatic conflu-
above the umbilicus can be used in living donors
ence around IVC. The MHV and LHV are dissected and
encircled by a sling, respectively or patients with tumors measuring less than 5 cm
[3]. After dissection at the liver hilum and hepatic
venous confluence near IVC, the hanging tape
3.2 Hanging Maneuver can be located along the anteromedian surface of
the retrohepatic IVC or the ligamentum venosum
The hanging maneuver proposed by Belghiti with its upper end among the three hepatic veins
et al. during right hepatectomy using a tape pass- and its lower end among the three Glisson’s ped-
ing between the anterior surface of the inferior icles. The tape on the retrohepatic IVC can be
vena cava (IVC) and the liver parenchyma has positioned not only via retrohepatic tunneling but
several advantages in major hepatic resection [1]. also after liver mobilization (Fig. 3.3).
The tape used in this procedure plays two impor- Occlusion of one to two of the three Glissonian
tant roles: first, as a guide to the transection plane, pedicles, which supply the resected hepatic sec-
and second, as a means to control the liver. tion, reveals the demarcation line on the liver sur-
Pulling and aiming at the tape surrounding the face that corresponds to a transection plane. The
transection plane facilitate the exposure and parenchymal transection is performed with the
bleeding control of the deep portion of the paren- ultrasonic dissection device and usually proceeds
chyma, protecting the retrohepatic IVC and the from the bottom to the top and from the front to
main Glissonian pedicle and hepatic vein of the the back along the line with both ends of the tape
3 The Safe Application of Hanging Maneuver 15

The division of hilar Glissonian pedicle and

hepatic vein around IVC of the resected section
of liver can be done before or after parenchymal
transection. However, the author prefers cutting
after parenchymal transection, because only after
complete parenchymal transection is the
Glissonian pedicle or hepatic vein exposed
widely to secure sufficient space for stapling or
clamping, and division to prevent injuries such as
strictures or occlusions involving artery, portal
vein, or bile duct within the Glissonian sheath or
hepatic vein of the remaining liver. The Glissonian
pedicle can be divided not only en masse but also
Fig. 3.3 After liver mobilization, a tape for the hanging
maneuver is positioned along the IVC with its upper end individually after dissection into its artery, portal
located between the RHV and MHV and its lower end on vein, and bile duct similar to surgeries involving
the left side of the two right inferior hepatic veins hilar cholangiocarcinoma or living donors [4].
To enhance the application of the hanging
oriented and pulled up for the transection plane, maneuver, the inferior portion of caudate lobe
if necessary, using the Pringle maneuver and con- under the hepatic hilum is transected until the
tinued cephalad and posteriorly aiming at the branch point of the main Glissonian pedicle. The
tape until the tape is exposed. The maneuver lower end of the tape located on the anteromedial
should not be attempted in case of tumors invad- surface of the IVC is repositioned between the
ing or abutting the retrohepatic IVC, the extrahe- three Glissonian pedicles already dissected. Only
patic three Glissonian pedicles, or the three after this transection can the hanging tape encir-
hepatic veins because the dissection to locate a cle the transection plane smoothly to facilitate
hanging tape at the live hilum or hepatic venous pulling up of the hanging catheter [5].
confluence may induce profuse bleeding or tumor
spillage.
In case of living donor right hepatectomy, in 3.4 Single Tape along
the presence of sizable venous branches of the the Anterior Surface
anterior section, the parenchymal transection is of Retrohepatic IVC
performed until those venous branches, and the
hanging tape can be repositioned in order to pre- Right posterior sectionectomy without the RHV
serve the venous branches. is possible if its upper end is on the right side of
Anatomic major liver resection requires four the RHV and its lower end lies between the right
major steps entailing mobilization of the resected anterior and posterior Glissonian pedicles.
hepatic section, dissection of hilar Glissonian Right posterior sectionectomy with the RHV
pedicles, parenchymal transection, and dissec- or left trisectionectomy with the caudate lobe is
tion of hepatic venous confluence around supra- facilitated by the location of its upper end
hepatic IVC. between the RHV and MHV, and its lower end
During the hanging maneuver, the other three between the right anterior and posterior
steps are performed before parenchymal Glissonian pedicles (Fig. 3.4a).
­transection. However, the parenchymal transec- Right hepatectomy without MHV or left hepa-
tion may precede or follow the mobilization of tectomy with the caudate lobe and MHV is
the resected liver section similar to the anterior enabled if its upper end lies between the RHV
approach hepatectomy or living donor surgery, and MHV, and its lower end is between the right
respectively. and left Glissonian pedicles (Fig. 3.4b).
16 S. H. Kim

Right anterior sectionectomy without the

MHV is possible if the upper end of one tape lies
between the RHV and the MHV, and its lower
end is between the right anterior and posterior
Glissonian pedicles, and the upper end of the
other tape is between the RHV and MHV, and its
lower end is between the right and left Glissonian
pedicles (Fig. 3.4a, b).
Right anterior sectionectomy with the MHV is
possible if the upper end of one tape lies between
the RHV and MHV, and its lower end is between
the right anterior and posterior Glissonian pedi-
cles, and the upper end of the other tape is between
the MHV and LHV and its lower end is between
the right and left Glissonian pedicles (Fig. 3.4a–c).
Left medial sectionectomy without the MHV
Fig. 3.4 Locations of the hanging tape along the antero- is possible if the upper end of one tape lies
median surface of the retrohepatic IVC
between the MHV and LHV, and its lower end is
between the right and left Glissonian pedicles
Right hepatectomy with the MHV or left hep- with both the ends oriented towards the border of
atectomy with the caudate lobe is possible if its the right and left liver, and the upper end of the
upper end lies between the MHV and LHV, and other tape is between the MHV and LHV, and its
its lower end between the right and left Glissonian lower end is between the right and left Glissonian
pedicles (Fig. 3.4c). pedicles with both the ends oriented clockwise
Right trisectionectomy is indicated if the close to the right side of the umbilical portion of
upper end of the tape is between the MHV and the left Glissonian pedicle and pulled up in the
LHV, and its lower end is between the right and direction (Fig. 3.4c, d).
left Glissonian pedicles, and both the ends are Left medial sectionectomy with the MHV is
pulled up close to the right side of the umbilical facilitated if the upper end of one tape lies
portion of the left Glissonian pedicle (Fig. 3.4d). between the RHV and MHV, and its lower end is
located between the right and left Glissonian
pedicles, and the upper end of the other tape is
3.5 Two Tapes along the Anterior between the MHV and LHV, and its lower end is
Surface of Retrohepatic IVC between the right and left Glissonian pedicles
(Fig. 3.4b–d).
Central bisectionectomy is favored if the upper
end of one tape is between the RHV and MHV
and its lower end is located between the right 3.6 One Tape along
anterior and posterior Glissonian pedicles, and the Ligamentum Venosum
the upper end of the other tape is between the
MHV and LHV and its lower end is between the The prerequisites for a successful liver hanging
right and left Glissonian pedicles with both the maneuver are accurate positioning of tape based
ends oriented clockwise close to the right side of on liver anatomy and surgical feasibility. For left
the umbilical portion of the left Glissonian pedi- hepatectomy, if the lower end of the hanging tape
cle and pulled up in the direction (Fig. 3.4a–d). is placed between the right and left Glissonian
3 The Safe Application of Hanging Maneuver 17

pedicles similar to dissection of the right

Glissonian pedicle during right hepatectomy, the
caudate pedicle branching from the left
Glissonian pedicle may be subject to injury
because it lies on the transection plane, which
can trigger atrophy or bile duct dilatation of the
caudate lobe (Fig. 3.5a). This problem can be
avoided by dissecting the left Glissonian pedicle
along with the ligamentum venosum and using a
hanging tape dorsally on the ligamentum veno-
sum (Fig. 3.5b) [6].
Left hepatectomy via MHV or right hepatec-
tomy with the caudate lobe is facilitated if the
upper end of the tape is between the RHV and
MHV and its lower end is located between the
right and left Glissonian pedicles (Fig. 3.6a–o).
Left hepatectomy without MHV or right hepa- Fig. 3.6 Locations of the hanging tape along the liga-
tectomy with the caudate lobe and MHV is mentum venosum
enabled when the upper end of tape lies between
the MHV and LHV and its lower end is located right side of the umbilical portion of the left
between the right and left Glissonian pedicles. Glissonian pedicle (Fig. 3.6b–o).
Right trisectionectomy with the caudate lobe or Left trisectionectomy without the caudate
living donor left lateral sectionectomy is indi- lobe or right posterior sectionectomy with the
cated when the tape lies in the same position and caudate lobe is facilitated if its upper end is
both the ends of the tape pulled up close to the located between the RHV and MHV, and its
lower end is between the right anterior and poste-
rior Glissonian pedicles (Fig. 3.6a–c).
Left lateral sectionectomy is possible if its
upper end is between the MHV and LHV and its
lower end is in the left side of the umbilical por-
tion of the left Glissonian pedicles.

3.7 One Tape along the Anterior

Surface of the Retrohepatic
IVC and Ligamentum
Venosum

Isolated caudate lobectomy is facilitated if the

upper end of the tape located between the RHV and
MHV along the IVC is passed through a tunnel
Fig. 3.5 Methods of dissection of the left Glissonian behind the common trunk of the MHV and LHV,
pedicle for positioning a hanging tape in left hepatectomy.
LGP left Glissonian pedicle. LV ligamentum venosum, pulled down along the ligamentum venosum, and
CP caudate pedicle laid under the hepatic hilum (Fig. 3.7) [7].
18 S. H. Kim

Fig. 3.8 Hanging maneuver for parenchymal transection

during right inferior sectionectomy (resection of segments
5 and 6)

Fig. 3.7 Location of the tape for hanging maneuver in

the isolated caudate lobectomy

3.8 Other Types of Liver

Resection by Hanging
Maneuver

Right inferior sectionectomy (resection of seg-

ments 5 and 6) is indicated after the right liver is
partially mobilized, and some parenchymal tran-
section along the inferior side of right Glissonian
pedicle shows Glissonian branches of segments 5
and 6. The dissection and temporary occlusion of
the Glissonian branches reveals the demarcation
Fig. 3.9 Hanging maneuver during resection of segment
line of segments 5 and 6 on the liver surface. The 4b and 5 for gallbladder cancer
hanging tape is used to surround the transection
plane and the parenchymal transection is per-
formed with both ends of the tape pulled up totally with the tape pulled up in line with each
(Fig. 3.8). transection plane. It may be useful in extended
Extended right posterior sectionectomy is cholecystectomy (Fig. 3.9).
facilitated when both ends of the tape positioned
at the border of right anterior and posterior sec-
tions are rotated clockwise toward the right ante- References
rior Glissonian pedicle. Parenchymal transection
occurs via division of the right-sided branches of 1. Belghiti J, Guevara OA, Noun R, Saldinger PF,
Kianmanesh R. Liver hanging maneuver: a safe
the right anterior Glissonian pedicle so that the approach to right hepatectomy without liver mobiliza-
remaining liver can carry intact Glissonian pedi- tion. J Am Coll Surg. 2001;193(1):109–11.
cle and draining vein. 2. Kim SH, Park SJ, Lee SA, Lee WJ, Park JW, Hong
Resection of segments 4b and 5 is also feasi- EK, et al. Various liver resections using hanging
maneuver by three glisson's pedicles and three hepatic
ble. This type of liver resection has three transec- veins. Ann Surg. 2007;245(2):201–5.
tion planes. The hanging maneuver can be applied 3. Kim SH, Kim YK. Upper midline incision for liver
during parenchymal transection partially or resection. HPB (Oxford). 2013;15(4):273–8.
3 The Safe Application of Hanging Maneuver 19

4. Kim SH, Cho SY, Lee KW, Park SJ, Han SS. Upper 6. Kim SH, Kim YK. Hanging manoeuver for a left
midline incision for living donor right hepatectomy. hepatectomy using Glisson's approach with a focus
Liver Transpl. 2009;15(2):193–8. on tape position in liver hilum. HPB (Oxford).
5. Kim SH, Kim YK. Living donor right hepatectomy 2013;15(9):681–6.
using the hanging maneuver by Glisson's approach 7. Kim SH, Park SJ, Lee SA, Lee WJ, Park JW, Kim
under the upper midline incision. World J Surg. CM. Isolated caudate lobectomy using the hanging
2012;36(2):401–6. maneuver. Surgery. 2006;139(6):847–50.
 Left Hemihepatectomy
4
Jin Sub Choi

Abstract ­ iddle hepatic veins drain vessels from left

m
hemi-liver.
Left hemi-hepatectomy is a relatively easier
The indications for this type of resection are
surgical procedure than the other major hepa-
various benign or malignant tumors, direct inva-
tectomies. However, an indolent approach to
sion of the gastric malignant tumor, complex
left hemi-liver may result in fatal complica-
liver cystic diseases or intrahepatic duct stones
tions. Accurate understanding of hepatic
and finally traumatic liver injury involving seg-
hilum, biliary system, and hepatic vein is
ments 2, 3 and 4.
essential for acceptable surgical outcomes.
Patients with severe cardiopulmonary impair-
ment that cannot tolerate general anesthesia as
Keywords
well as those with distant metastasis or intraperi-
Left hemihepatectomy · Liver hilum · Bile toneal seeding of malignant tumor are contraindi-
duct anatomy · Cantlie line cated for surgery.
The patient is held on an operative table in
supine position, with the left arm attached to the
Left hemihepatectomy entails resection of the body.
left hemi-liver, which is supplied by the left por- The generally used xiphoumbilical median
tal vein and left hepatic artery (segments 2, 3, and incision is adequate to resect left hemi-liver but
4 according to the Couinaud classification). This occasionally other large incisions may be needed
area is located on the left side of Cantlie line and depending on tumor size: a transverse incision
simply identified after occlusion of the left portal may be combined with the median incision, or a
vein and the left hepatic artery. The left and bilateral subcostal incision alongside upper
median extension (Fig. 4.1).
Mobilization of left hemi-liver is the first step
Supplementary Information The online version con- in this surgery and is completed by division of the
tains supplementary material available at https://doi. umbilical, the falciform, the left coronary, and
org/10.1007/978-­981-­16-­1996-­0_4. the left triangular ligaments (Fig. 4.2).
Division of the falciform ligament occurs
J. S. Choi (*) along the anterior surface of IVC to expose the
Division of Hepatopancreaticobiliary Surgery, right hepatic, the left hepatic, and the middle
Department of Surgery, Yonsei University College of hepatic vein inlets into the IVC (Fig. 4.3).
Medicine, Seoul, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 21

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_4
22 J. S. Choi

Fig. 4.1 Various types of skin incision

Fig. 4.2 Dissection of Left phrenic vein

the left coronary and the Diaphragm
left triangular ligaments

Left triangular
ligament

Diathermy

Left coronary ligament

The anterior leaflet of the left coronary ligament

is divided from the left side of the left hepatic vein
and IVC, and proceeds to the left side. Occasionally,
the left diaphragmatic vein crosses the left coro-
nary ligament, and it should be ligated and divided.
The left triangular vein also must be ligated and
divided to avoid unnecessary bleeding.
Division of the lesser omentum is the next step
in liver mobilization. The lesser omentum should
be divided close to the liver parenchyma with
great care to identify accessory or aberrant left
Fig. 4.3 Dissection of the falciform ligament exposes the hepatic artery from the left gastric artery or celiac
anterior wall of inferior vena cava and common trunk of
the middle and left hepatic veins
trunk (Fig. 4.4).
4 Left Hemihepatectomy 23

Fig. 4.4 The lesser omentum often contains aberrant left

hepatic artery

Fig. 4.5 Variation of the biliary system

The hilar dissection is performed after com-
pletion of liver mobilization. The umbilical liga-
ment is pulled upward, and the cholecystectomy
is carried out initially. The anatomy of bile duct
should be identified by MRCP before operation
or via intraoperative cholangiography to identify
any bile duct variant (Fig. 4.5).
The anterior peritoneum of hepatoduodenal
ligament is divided transversely. The common
hepatic, right hepatic, middle hepatic, and left
hepatic arteries are identified via careful dissec-
tion of loose connective tissue and neural plexus
in the hepatoduodenal ligament (Fig. 4.6).
The left and middle hepatic arteries are divided
Fig. 4.6 Dissection of liver hilum
after double or fixed ligatures. Below the artery,
the left surface of the main or left portal vein is
exposed following further dissection of loose capsule on the anterior surface is incised via elec-
connective tissue and neural plexus along the left trocautery as the parenchyma division line
side of hepatoduodenal ligament. The left portal (Fig. 4.9).
vein is identified after further cranial dissection The parenchymal division is conducted via
(Fig. 4.7). classical Kelly clamp crushing or with an ultra-
A few small caudate branches are found on the sonic device or other energy devices. The paren-
posterior aspect of the left portal vein, 1–2 cm chymal division proceeds from the caudal area to
from the main portal bifurcation, and saved to the cranial side between the right side of sagittal
preserve caudate blood flow (Fig. 4.8). hepatic vein and the left side of middle hepatic
The left portal vein is divided above the cau- vein along the Cantlie line. The left hilar plate
date branch between double or transfixed liga- should not be damaged during parenchymal divi-
tures. The left bile duct is not handled during this sion to protect the right posterior bile duct, which
stage and will be managed during parenchymal runs into the left hepatic duct. The left hepatic
division. duct encountered during parenchyma division is
The left hemi-liver becomes ischemic after the divided as far as possible from main duct bifurca-
left portal vein ligation. The ischemic demar- tion via en-bloc ligature or transfixed stitch using
cated area is easily identified, and the Glisson a 4-0 monofilament suture (Fig. 4.10).
24 J. S. Choi

Fig. 4.7 Dissection of the left

portal vein

Left Hepatic Artery

Left Portal Vein

Fig. 4.8 Caudate

branch of the left portal
vein Left Portal Vein

Caudate
Branch

The parenchymal division into common trunk

of the middle and left hepatic veins continues
after division of the medial branch of the middle
hepatic vein. The left hepatic vein is clamped
and divided, and the stump of the left hepatic
vein is sutured with 5-0 monofilament running
stitches.
Any bleeding must be controlled via electro-
cautery, sutures, or topical agents. Any bile leak-
age or bile duct damage must be controlled
appropriately.
The operation is completed after positioning
the closed suction drain in the dead space.
Fig. 4.9 Discoloration of the left liver along the Cantlie
line
4 Left Hemihepatectomy 25

Fig. 4.10 Division of Right Posterior Duct

the left bile duct
avoiding injury to the
right posterior bile duct

Division line of the left bile duct

 Right Hemihepatectomy
5
Yoon Jin Hwang and Hyung Jun Kwon

Abstract right liver. The right hepatectomy is a major

liver resection that requires preoperative liver
The right hemihepatectomy is a standardized
function, resectability, and assessment of future
procedure. It entails resection of liver paren-
liver remnant (FLR) volume.
chyma on the right side of the Cantlie line
towards the right of the middle hepatic vein.
Keywords
According to the new classification proposed
by the International Hepato-Pancreato-Biliary Liver · Surgery · Resection · Right
Association in 2000, the right hepatectomy Hepatectomy
entails resection of segments V, VI, VII, and
VIII. The right hepatectomy is mostly indicated
for primary liver or biliary malignancies involv- 5.1 Position
ing metastatic tumors, particularly metastatic
colorectal cancer. Less frequently, this opera- The patient is placed in supine position with the
tion is indicated for large, symptomatic benign right arm at 90° of abduction.
tumors or for large retroperitoneal tumors
involving the right liver. Rarely, liver or biliary
infections or bile duct injuries are an indication 5.2 Laparotomy
for the right hepatectomy. Tumors involving the
main inflow pedicle and/or outflow venous Although various laparotomy approaches can be
drainage to the right liver typically require right used, generally, an inverted L-incision is made as
hepatectomy for removal. Similarly, this proce- a median incision extending to the right at a 90°
dure is required for diffuse tumors involving angle. The incision to the right can be extended
most of the parenchyma or all segments of the as needed, and the incision should be at least
2–3 cm away from the costal margin. The xiphoid
process can be removed to secure the surgical
Supplementary Information The online version con-
tains supplementary material available at https://doi.
field of view, and the round ligament at the bot-
org/10.1007/978-­981-­16-­1996-­0_5. tom of the median incision is used to pull the
liver during liver resection. After the falciform
ligament is dissected in a cephalad direction, two
Y. J. Hwang (*) · H. J. Kwon
Department of Surgery, School of Medicine,
retractors are used to retract both the costal mar-
Kyungpook National University, Daegu, South Korea gins to expose the right upper quadrant.
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 27

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_5
28 Y. J. Hwang and H. J. Kwon

5.3 Mobilization of Right Liver ing the right wall of the inferior vena cava, the
and Identification of Right right liver is retracted and elevated left anteriorly
Hepatic Vein to dissect between the inferior vena cava and the
liver, and short hepatic veins may be exposed in
A longitudinal incision is made on the right side the process. Short hepatic veins are sequentially
of the hepatoduodenal ligament for ligation, and ligated and cut to reach the left side of the inferior
cutting of the cystic artery and duct. After resec- vena cava, cautious about occasional re-bleeding
tion of the gallbladder, as the right liver is from ligation sites. If necessary, the stump on the
wrapped with gauze and retracted downward left inferior vena cava side can be ligated once or
in a rolling motion, the falciform and the right twice and additionally clipped above the ligation
coronary ligaments are dissected. The falciform site to prevent loss of the ligation. Larger short
ligament is first dissected from the abdominal hepatic veins may be continuously sutured with
wall until the inferior vena cava of the upper liver Prolene to prevent bleeding. After ligation of the
is exposed. The right coronary ligament is then short hepatic veins, the gap between the middle
dissected as close to the liver as possible to pre- hepatic vein and the right hepatic vein along the
vent bleeding from damage to diaphragm and its anterior side of the inferior vena cava on the cra-
vessels. At this time, the connective tissue nial side can be identified. Kelly forceps are
between the middle hepatic vein and the right inserted along the gap from the caudal to the cra-
hepatic vein is dissected, and the right hepatic nial sides, and the Penrose drainage tube is passed
vein is identified. The right liver is then retracted around the right hepatic vein for elevation during
upwards left to dissect the right triangular liga- the hanging maneuver.
ment to advance into the bare area. As the right
liver is retracted in a cephalad direction, the hep-
atorenal ligament is dissected to expose the ante- 5.4 Hepatic Hilum Manipulation
rior wall and the right wall of the inferior vena
cava. As the right liver is retracted upwards left 5.4.1 Hepatic Hilar Vessel
once again, the dissection of the bare area dissec- Manipulation
tion downwards exposes the anterior side of the
right adrenal gland. In some cases, the right adre- The bile duct is first located, and the cystic duct
nal gland is firmly adhered to the right liver, caus- stump suture is pulled with tonsil forceps, fol-
ing excessive bleeding during the dissection. In lowed by longitudinal dissection of the connec-
these cases, instead of dissecting the adrenal tive tissue below the bile duct on the right side
gland from the liver, after inserting tonsil forceps towards the hilum. The right hepatic artery is
in a cephalad direction from the caudal side identified. The right hepatic artery is blocked by
between the adrenal gland and the right wall of pulling the previously inserted Penrose drainage
the inferior vena cava, vascular clamps are tube and using the Bulldog vascular clamp. The
applied to the sides of the liver and the adrenal course and the blood flow of the left hepatic
gland, cut between them, and the cut surfaces are artery is then determined. Note that the aberrant
continuously sutured with Prolene. On the cranial right hepatic artery can be identified at a fre-
side, the right wall of the inferior vena cava is quency of 10–15%. Once the left hepatic artery
exposed after the ligation and cutting of the firm has been evaluated, the right hepatic artery is
inferior vena cava ligament. Occasionally, short ligated twice and cut (Fig. 5.1). The right wall of
hepatic veins or right posterior hepatic veins are the portal vein is exposed by dissecting connec-
located close to the inferior vena cava ligament. tive tissue on the dorsal side of the right hepatic
In such cases, the tonsil forceps must be inserted artery while pulling the extrahepatic bile duct and
in a cephalad direction from the caudal side, the right hepatic artery to the left with vein retrac-
ensuring that the veins are not injured during the tors. When the right wall of the portal vein is
ligation and cutting of the ligament. After expos- exposed, the anterior wall of the right portal vein
5 Right Hemihepatectomy 29

Fig. 5.2 Identification of the right portal vein. The right

wall of the portal vein is exposed as the extrahepatic duct,
and the right portal vein is retracted to the left with the
Fig. 5.1 Ligation of the right hepatic artery. The right vein retractors. The connective tissue dorsal to the right
hepatic artery can be identified via longitudinal dissection hepatic duct is dissected
of the connective tissue towards the portal vein, followed
by retraction caudate lobe, each side of the demarcation line is
suture-ligated with 3-0 Prolene. While retracting
is dissected to expose the root of anterior and the sutures, the liver parenchyma is transected to
posterior branches. The anterior side of the portal a depth of 2–3 cm.
vein is then exposed. After evaluating the root of
the left and right portal veins, pulling the right
portal vein in the caudad direction with the 5.4.2 Manipulation of Glisson
Debakey forceps at the root of the right portal Pedicle
vein, the dissection is advanced dorsally from the
cranial side. Any caudate branch encountered The Glisson capsule covering the left and right
should be ligated and cut carefully to prevent branches of the Glisson pedicle is cut horizon-
tears. The same dissection is performed in a tally at the lower margin of quadrate lobe, with an
cephalad direction from the ventrodorsal side, electric cautery machine, and the hilar plate is
hang the right portal vein with the vessel loop dissected from the liver parenchyma using the
using the Mixter forceps (Fig. 5.2). After the suction tip. In the process, a thin Glisson pedicle
above dissection is completed, the blood flow of may be encountered, which is ligated and cut
the right hepatic artery and the right portal vein is with care. After the dissection is completed ade-
blocked temporarily using the Bulldog vascular quately 1 cm to the left and the right, it is
clamp, and the area of blood flow blockage along advanced dorsally. Even if bleeding occurs in the
the Cantlie line is determined. The ligation of the liver parenchyma, it can be easily controlled by
right hepatic artery and the right portal vein may applying pressure and proceed to the next step.
be performed before or after the parenchymal While inserting Mixter forceps from the dorsal to
transection as needed. Using the vein retractor, the caudal side, penetrating the space between
the hepatoduodenal ligament is pulled to the left the Glisson capsule and the liver parenchyma, the
at a 45° angle, to identify the caudate lobe below hepatoduodenal ligament is pulled using the vein
the right hepatic portal vein. After the demarca- retractor at a 45° angle to the left, to evaluate
tion line is drawn using an electric cautery below the ligament. If resistance is felt at the end
machine on the right margin of the inferior vena of the Mixter forceps, it is important not to force
cava at the boundary of the right lobe and the the insertion, instead, the area with the least resis-
30 Y. J. Hwang and H. J. Kwon

number, and the positional relationship of the

intrahepatic structures of the tumor, especially the
location of the middle hepatic vein and its
branches, using intraoperative ultrasound. It is
more advantageous to perform the liver transec-
tion 1 cm left of the demarcation line on the sur-
face of the liver. A stay suture with No.0 chromic
is used for the traction of the imaginary transec-
tion line to the left and the right at the lower edge
of the liver. The two methods of liver transection
include the CUSAⓇ and the Kelly forceps. The
liver parenchyma is crushed using the CUSAⓇ or
the Kelly forceps, followed by cauterization of the
remaining Glisson pedicle and hepatic vein
Fig. 5.3 Manipulation of the Glisson pedicle and the
branches with an electrocautery machine, and the
Penrose drainage tube insertion. The hepatic hilum is dis-
sected from the liver parenchyma, and the Penrose drain- larger branches are clipped or ligated. The goal of
age tube is inserted between the Glisson capsule and the liver transection is to proceed broadly and thinly
liver parenchyma in order to easily stop the bleeding of the hepatic
vein. The liver transection proceeds along the
tance should be selected, in order to avoid dam- right margin of the middle hepatic vein. When
age to the Glisson pedicle. After dissection, the more than 50% of liver transection is completed,
previously inserted Penrose drainage tube is including the liver parenchyma in the hilar direc-
passed along the transection site of the caudate tion, the liver transection is continued after elevat-
lobe and placed at the back of the treated Glisson ing the Penrose drainage tube that was previously
pedicle (Fig. 5.3). passed through the gap between the right hepatic
vein and the middle hepatic vein for the hanging
maneuver (Fig. 5.4). Hanging maneuver reduces
5.5 Liver Resection

For liver transection, it is recommended to lower

the central venous pressure to 5 cm H2O or less. In
order to reduce the amount of bleeding during
liver transection, the Pringle technique, which
intermittently blocks and reperfuses the liver via
hepatic artery and the portal vein as needed, is
used. After making an incision in the avascular
area of the lesser omentum on the left side of the
hepatoduodenal ligament, the right-angle clamp
is passed under the hepatoduodenal ligament and
covered with the umbilical tape. The blood circu-
lation is regulated by the tape on the tourniquet.
Until the liver transection is completed, the blood
flow is repeatedly blocked for 15 min, and then
reperfused for 5 min. The liver transection is car- Fig. 5.4 Transection of the liver parenchyma. After
crushing the liver parenchyma, the remaining Glisson
ried out considering the tumor location and the
pedicle and hepatic vein branches are cauterized with an
demarcation line on the liver surface. The liver electrocautery machine, and the larger branches are
transection is performed after identifying the size, clipped or ligated
5 Right Hemihepatectomy 31

the anterior dissection area of the inferior vena

cava which is invisible. It also reduces bleeding
by compressing the transection surface. Also, it is
possible to maintain the parenchymal transection
direction along the straight plane of transection. If
the right hepatic artery and the right portal vein
branches are not ligated before the liver transec-
tion, the right hepatic duct, the right hepatic artery,
and then the right portal vein branches are ligated,
cut, and elevated. After the transection of the liver
parenchyma, the right hepatic vein is ligated in
the last step using the vascular TAⓇ.

5.6 Drainage Tube Insertion, Fig. 5.5 Evaluation of the transection surface and fixa-
Closure tion of the falciform ligament. The liver transection sur-
face, ligated bile duct, and vessels are evaluated for
bleeding and leakage, and the falciform ligament is fixed
The Jackson-Pratt drainage tube is placed below
the right diaphragm, in the direction of the tran-
section surface and the abdomen is closed. bleeding cannot be controlled. When the leak test
is performed, a tube with a small diameter is
inserted through the cystic duct, indigo carmine
5.7 Bleeding Control, Bile pigment mixed with normal saline is injected to
Leakage Test and Fixation evaluate leakage, and the leaked area is closed
of Falciform Ligament with sutures.
The falciform ligament should be fixed to
In the event of bleeding from the liver transection the abdominal wall in its original position to
surface, the bleeding site is cauterized using tools prevent the rotation of the remaining left liver
like argon beam coagulator or sutures if the (Fig. 5.5).
 Central Bisectionectomy
6
Kyung Sik Kim

Abstract Extended hepatectomy or non-anatomical liver

resection is indicated for tumors located in the
Central bisectionectomy (mesohepatectomy)
Couinaud segments 4, 5, and 8 (Fig. 6.1a).
is a procedure used to resect the central region
However, in the case of extensive hepatic resec-
of the liver (IVA, IVB, V, and VIII) that drains
tion, a large portion of the liver parenchyma is
into the middle hepatic vein. It can be used to
removed, and the remaining liver volume is
overcome the challenges due to insufficient
small, leading to liver failure and mortality.
residual liver volume by reducing the volume
Therefore, there are limitations in surgical
of resected liver. The safety procedure has
approach for patients with liver cancer accompa-
been established after improvement in the
nied by liver cirrhosis.
understanding of liver anatomy and the devel-
Central bisectionectomy (mesohepatectomy)
opment of surgical equipment.
is a procedure used to remove the central region
of the liver (IVA, IVB, V, and VIII) that drains
Keywords
into the middle hepatic vein [1]. This procedure
Central bisectionectomy · Mesohepatectomy was first attempted in 1972 with a patient with
Middle hepatic vein · Extensive hepatic gallbladder cancer. It has been applied in patients
resection · Insufficient residual liver volume with bile duct and liver cancer. It can be used to
Liver failure overcome the challenges due to insufficient resid-
ual liver volume by reducing the volume of
resected liver. The safety of the procedure has
been established with the advancement in under-
standing of liver anatomy and the development of
surgical equipment. It can also be performed as a
laparoscopic surgery [2].
Supplementary Information The online version con-
tains supplementary material available at https://doi.
org/10.1007/978-­981-­16-­1996-­0_6.

K. S. Kim (*)
Department of Hepatobiliary and Pancreatic Surgery,
Severance Hospital, Yonsei University College of
Medicine, Seoul, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 33

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_6
34 K. S. Kim

a b

c d

Fig. 6.1 (a) The CT scan showed the uptake of lipiodol surfaces of the residual liver following delivery of the
in the hepatocellular carcinoma located in Segment VIII. specimen exposing portal and hepatic veins. (d) The fol-
(b) The dissection planes determined by intraoperative low-up CT scan taken at postoperative seventh day. RHV
ultrasonography were marked along the medial side of the right hepatic vein, LHV left hepatic vein, RPV right portal
falciform ligament and right anterior fissure. (c) The raw vein, LPV left portal vein

6.1 Preoperative Preparation 6.2 Operative Procedures [3]

Liver function must be evaluated based on the Skin incision can be made in several ways, but in
Child-Pugh score and the ICG R15 test. my experience, the skin incision is made right
Computed tomography (CT) and abdominal under the sternum along with a midline of about
magnetic resonance imaging (MRI) are per- 4 cm, spanning the ribs until the right anterior
formed prior to surgery to evaluate the resectabil- axillary line. A subcostal transverse skin incision
ity and the anatomy of blood vessels and bile is made. A part of the falciform ligament and the
ducts. Recently, it has been possible to obtain left and right coronary ligaments are divided to
increasingly accurate information via 3D image expose the whole liver. The left triangular liga-
reconstruction using CT or MRI data. Also, the ment is not resected to prevent the instability of
estimation of the resecting and remaining volume the remaining hepatic parenchyma after the
of the liver is very important in preparation for resection of the central zones. Later, the retractor
possible liver failure after surgery. is applied to ensure the operative field.
6 Central Bisectionectomy 35

The two blades of the retractor are used in the event of extensive bleeding, the blood circulation
left and the right sides of the median incision and should be temporarily blocked to the left hepatic
one blade of the retractor is applied at the end of artery and portal vein, which were previously iso-
the right subcostal incision. If necessary, an addi- lated and looped, to induce ischemia. Hemostasis
tional retractor blade compressing the gastroin- is induced by packing gauze on the resected sur-
testinal tract is used to prevent protrusion. face to treat the middle vein when the hepatic
Intraoperative ultrasonography is performed to parenchymal resection reached the middle
confirm the location of tumor and the course of venous root under a good field of view. Hepatic
surrounding vessels and bile duct. The location of parenchymal resection of the right anterior seg-
the tumor, its spread to the surrounding area, liver ment is initiated to the left along the direction of
metastasis, and tumor embolism in the portal the right hepatic vein marked in advance, expos-
vein or hepatic vein are also evaluated. At this ing the root of the right hepatic vein, and simulta-
time, the three-dimensional relationship between neously continuing to cut toward the hepatic
the tumor and the related veins like portal vein portal, cutting the parenchyma on the left. When
and hepatic vein is confirmed to establish the the right anterior Glisson’s sheath is exposed,
resection boundary. A mark is made between the double-ligation or hemlock is used to cut. After
driving direction of the right hepatic vein and the lifting the center 2 area liver parenchyma, the
left and inner and outer regions (Fig. 6.1b). middle vein is ligated using an automatic vascu-
Next, the cystic duct and the cystic artery are lar suture (Fig. 6.1c).
divided to expose the hepatic hilum, and the left A schematic diagram of the central bisectio-
side of the right hepatic artery, the left side of the nectomy is shown in Fig. 6.2.
right hepatic portal vein, and the common hepatic Since biloma formation is the most common
duct are detached and taped. Vascular isolation complication in central bisectionectomy, it is
techniques are used to minimize bleeding during very important to confirm the absence of biliary
parenchymal resection, to reduce residual liver fistula in the branches of the bile duct. In the past,
ischemic damage, and to delineate the resection biliary tract imaging was performed during sur-
boundary. In particular, it is necessary to note the gery, but recently, injection into the cystic duct
direction of the pathway of the middle hepatic using air and saline or a fluid containing lipid has
artery while performing a meticulous hepatic dis- been used to confirm damage to the bile duct. In
section. Parenchymal resection is carried out by the case of methylene blue, it can be seen clearly
pulling the round ligament upward, lifting the left at first, but is not recommended because the sur-
liver upward, and starting the parenchymal resec- rounding tissue is stained, thus disabling further
tion at the right side of the umbilical fissure first, identification. When no further bleeding from the
then heading to the medial region. The liver resection surface or damage to the biliary tract is
parenchyma is divided with CUSA®. The arterial detected, the drainage tube is mounted on the
branch, portal branch, and bile duct entering the resection surface similar to the conventional pro-
liver area 4 from the front are ligated, but in the cedure, and the abdominal wall is closed.
36 K. S. Kim

a b

Fig. 6.2 (a) Schematic figures of the central bisectionec- right anterior section is transected. After the specimen is
tomy. The tumor is located at segments 4 and 5 of the liver delivered, MHV, RHV, and lVC are exposed at raw sur-
above the middle hepatic vein (MHV). (b) The medial face of the residual liver. IVC Inferior vena cava, MHV
aspect of the falciform ligament is transected firstly, and middle hepatic vein, HA hepatic artery, PV portal vein

6.3 Postoperative Care Recent trends in intraperitoneal drainage sug-

gest that intrahepatic jejunal anastomosis is not
Common complications that can occur after cen- needed during partial hepatic resection. In some
tral bisectionectomy include biliary tract leakage, cases, drainage is not performed, but in the case
pleural effusion, ascites, wound infection, abscess of central bisectionectomy, it is recommended to
in the abdominal cavity, and liver failure perform closed suction drainage to prevent retro-
(Fig. 6.1d). In the case of liver resection without grade infection. In my experience, abdomen CT
reconstruction of the biliary tract, the possibility is performed to evaluate liver regeneration and
of biliary leakage which depends on the presence fluid retention in the abdominal cavity on 5 days
or absence of cirrhosis is reported to be about after surgery. The drainage tube is removed when
4–12%. The possibility of bile leakage from there is no bile collection or the signs of infection
small-sized bile duct cannot be predicted by in the abdominal cavity. Conservative treatments
intraoperative bile leakage tests. In the case of such as enteral nutrition is considered with the
bile leakage, dead spaces after hepatic resection improvement of patient’s condition.
can lead to bacterial overgrowth, so proper fol- From January 1998 to April 2007, 27 cases of
lowing treatments are needed. Recently, non-­ central bisectionectomy for liver cancer in the cen-
surgical drainage is performed with good results. tral region were performed at Yonsei University
Intraperitoneal infection is often an unavoidable Severance Hospital [4]. The results show that the
complication and can even lead to sepsis if there operation time ranged from 215 to 669 min
is abscess in the abdominal cavity. For this rea- (median value of 330 min), and the amount of
son, a close postoperative monitoring is needed bleeding ranged from 550 to 7000 mL (median
during the entire admission period. In recent value 1400 mL). Postoperative resection margins
years, infection rate has decreased sharply, to less ranged from 0.1 to 4.0 cm (median value of
than 3%, which is attributed to several advances 1.5 cm). Postsurgical complications occurred in 12
in the management of hepatic resection. cases including 5 cases of biloma, 5 cases of pleu-
6 Central Bisectionectomy 37

ral effusion, and 2 cases of ascites. Conservative References

treatment such as percutaneous bile drainage was
required. There were eight cases of recurrence 1. Gallagher TK, Chan AC, Poon RT, Cheung TT, Chok
KS, Chan SC, Lo CM. Outcomes of central bisectio-
during the follow-up period (1.4–102.2 months, nectomy for hepatocellular carcinoma. HPB (Oxford).
median value 19.1 months). Therefore, a careful 2013;15(7):529–34.
follow-up is considered necessary. 2. Yoon YS, Han HS, Cho JY, Ahn KS. Totally lapa-
roscopic central bisectionectomy for hepatocellu-
lar carcinoma. J Laparoendosc Adv Surg Tech A.
2009;19(5):653–6.
6.4 Conclusion 3. Yanaga K. Central bisectionectomy (bisegmen-
tectomy) of the liver (with video). J Hepatobiliary
Despite the chance of biliary tract complications, Pancreat Sci. 2012;19(1):44–7.
4. Lee JG, Choi SB, Kim KS, Choi JS, Lee WJ, Kim
central bisectionectomy is one of the promising BR. Central bisectionectomy for centrally located hepa-
procedures that can be performed for the treat- tocellular carcinoma. Br J Surg. 2008;95(8):990–5.
ment of malignant tumors located in the middle
part of the liver, while preserving the volume of
the remaining liver.
 Left Lateral Sectionectomy
7
Tae-Jin Song

Abstract In recent years, due to the popularity of

laparoscopic hepatectomy, left lateral sectio-
The left lateral section, involving the second
nectomy is mostly performed via laparoscopy
and third segments of the left lobe of the liver,
or robotic minimally invasive surgeries.
is a frequent location of benign diseases such
as intrahepatic cholelithiasis and malignant
Keywords
diseases such as primary hepatocellular carci-
noma or metastatic cancer. Although it is con- Left lateral section · Left lateral sectionec-
sidered to be an area that is relatively easy to tomy · Atypical resection · Laparoscopic
access, severe peripheral adhesion due to resection · Robotic resection
repeated inflammation leads to deformation of
the anatomical structure via association with
the surrounding organs or after abdominal sur- The left lateral section, involving the second and
gery, and is often difficult to access or resect. third segments of the left lobe of the liver, is a
The lateral sectionectomy method during frequent location of benign diseases such as
liver resection depends on the surgical evalua- intrahepatic cholelithiasis, and malignant dis-
tion of the local lesion. Herein, anatomical eases such as primary hepatocellular carcinoma
resection of the second and third segments or metastatic cancer. It is the area that is consid-
alone has been discussed, and excludes wedge ered relatively easy to access. However, severe
resection and lesion-limited sub-segmental peripheral adhesion due to repeated inflammation
resection of segments 2 or 3, such as enucle- leads to deformation of the anatomical structure
ation and atypical liver resection. via association with the surrounding organs or
after abdominal surgery, and is often difficult to
access or resect. However, location in the lateral
segments 2 or 3 may interfere with pre- and post-­
Supplementary Information The online version con- operative evaluation depending on the preference
tains supplementary material available at https://doi. of each surgeon or different institution [1–3].
org/10.1007/978-­981-­16-­1996-­0_7.

T.-J. Song (*)

Department of Surgery, Korea University College of
Medicine, Korea University Ansan Hospital,
Ansan-si, Gyeonggi-do, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 39

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_7
40 T.-J. Song

The method of lateral sectionectomy during

liver resection depends on the surgical evaluation
of the local lesion. However, anatomical resec-
tion of the second and third segments alone is
discussed here, and excludes wedge resection
and lesion-limited sub-segmental resection of
segments 2 or 3, such as enucleation and atypical
liver resection.
Initially, during the surgery, the patient
assumes a position with the arms wide open or
attached to the body depending on conditions in
the supine position. Depending on the liver loca-
tion, it may be convenient to tilt the operating
table to raise the head (head-up position) or the
patient’s left-up position (left-up position),
depending each operation.
The left hepatic exposure is generally ade-
quate to open the epigastric midline, and in most
cases, this degree of incision ensures sufficient
observation and exposure around the lesion
(Fig. 7.1). If necessary, visibility can be extended
below the umbilical cord. Traction differs with
each trachea, such as the Kent retractor, but it is
good to perform traction to show the spleen out-
side the diaphragmatic adhesion site in the outer
Fig. 7.1 Incision during resection of the lateral section of
left lobe area from the left. To prevent spleen the liver
damage, the visual field is improved by placing
1–2 surgical cotton pads behind the spleen. The
Pringle maneuver is usually unnecessary for two- rotomy and double-ligated for traction. The left
to three-segment ablation, except in special cir- triangular ligament is used for traction by pulling
cumstances [3]. the left abdominal wall, and both the sides are
In the case of left lateral sectionectomy, the ligated and the liver is used for traction. If the
location of the operator and assistant on the right falciform ligament contains a lot of fat and is
side of the patient is often adequate, and depend- enlarged, or if it is stretched like a curtain, it
ing on the situation, it may be on the left side. should be removed via partial resection [4].
When standing on the right, the first assistant is Clearing and observation around the incision
located on the upper left and the second assistant margin after securing the field of view can estab-
is located on the lower left. In some cases, the lish the lesion via surgical ultrasound and deter-
position of the operator and the first assistant can mine the incision margin in the left lateral area.
be changed, but differs depending on the situa- The posterior side becomes the right left margin
tion. The liver is exposed first for the left lateral of the circular ligament. In most cases, the sec-
segment resection, to observe the lesion and the ond and third segments of the Glissonian branch
surroundings. As described above, the Pringle are separated, and the thread is slinged to prepare
maneuver is usually unnecessary, so just in case for ligation (Figs. 7.2, 7.3, 7.4 and 7.5). The
the hepatic duodenal ligament is wrapped with a parenchymal ablation of the liver can be started
cotton tape sling and pulled, only a tourniquet is after appropriate towing and marking for electro-
used for hemostasis. The umbilical ligament and surgery. Before parenchymal resection, the
the falciform ligament are cut during the lapa- Gleason branches 2 and 3 are ligated and sepa-
7 Left Lateral Sectionectomy 41

Fig. 7.2 The location of the hepatic vein branches and

the second and third Glissonian pedicles in the actual liver

Fig. 7.4 Clamping technique for No. 2 Glissonian branch

Sling

Fig. 7.3 Schematic diagram of the location of the hepatic

vein tributary and the second and third Glissonian
branches

rated (Figs. 7.4 and 7.5). Laparoscopic ultra-

sound scalpel (Harmonic scalpel®), which is
used in laparoscopic surgery, facilitates the initial
parenchymal resection. Monopolar or bipolar
electrosurgery is preferred by surgeons.
During parenchymal resection for hemostasis
of small blood vessels and bile ducts, if a branch
Fig. 7.5 No. 3 Glisson branch Sling
of the left hepatic vein is encountered, it is ligated
and cut with a sling (Figs. 7.2 and 7.3). During
parenchymal transection, small blood vessels Other areas are the same, but even if the inci-
developed, which interfered with hemostasis, or sion is small and not wide, special attention
additional hemostatic devices may be required if should be paid to bleeding. In some cases, closed
the patient has a history of anticoagulant use such suction drains, such as Jackson–Pratt drain may
as aspirin, but often it is not required for lesions be required. Similar to general open surgery, the
associated with the second or third segment. abdominal fascia is sutured, and the subcutane-
42 T.-J. Song

ous fat layer is closed. Even in open surgery, sub- References

cutaneous sutures are performed to cosmetically
enhance the skin. Adhesive glue for skin closure 1. Belli G, Fantini C, D'Agostino A, et al. Laparoscopic
segment VI liver resection using a left lateral decubitus
and an automatic skin stapler or approximating position: a personal modified technique. J Gastrointest
suture tape can be selected according to the oper- Surg. 2008;12:2221–6.
ator’s convenience and preference. The left outer 2. Fong Y, Sun RL, Jarnagin W, et al. Analysis of 412
section of the liver is more accessible than the cases of hepatocellular carcinoma at a Western center.
Ann Surg. 1999;229:790–9.
other places and can be relatively easy if it con- 3. Song TJ, Ip EW, Fong Y. Hepatocellular carcinoma:
tains an appropriate margin. The philosophical current surgical management. Gastroenterology.
differences between surgeons with different 2004;127:S248–60.
training at various institutions are minimal, and 4. Little SA, Fong Y. Hepatocellular carcinoma: current
surgical management. Semin Oncol. 2001;28:474–86.
opinions may differ slightly [1–3]. 5. Buell JF, Cherqui D, Geller DA, et al. The international
In recent years, due to the popularity of lapa- position on laparoscopic liver surgery: the Louisville
roscopic hepatectomy, left lateral sectionectomy statement, 2008. Ann Surg. 2009;250:825–30.
is mostly performed via laparoscopy or robotic
minimally invasive surgeries [1, 2, 5].
 Right Anterior Sectionectomy
8
Koo Jeong Kang and Keun Soo Ahn

Abstract
8.1 Introduction
The right anterior section consists of two seg-
ments, segment V and segment VIII. After Anatomical resection of hepatocellular carci-
clamp of the right anterior Glissonean pedicle noma require resection of the hepatic tumor
or individual right anterior portal pedicle, including non-tumor areas. It can also ensure
ischemic margin of anterior section can be oncologic and surgical safety. The liver consists
ensured. The hepatic parenchyma is transected of eight segments according to the distribution of
right and left according to the demarcation the portal and the hepatic venous systems. These
line. Further hepatic transection is performed segments are categorized into right anterior, right
toward the root of right and mid-hepatic veins. posterior, left medial, and left lateral sections
Finally, the right anterior section is removed. (Fig. 8.1) The function of each segment or sec-
In this chapter, the concept and technical tion is independent, with separate portal and
details of both open and laparoscopic resec- hepatic veins and biliary drainage. Hepatocellular
tions of right anterior sectionectomy are carcinoma spreads via retrograde flow of the por-
discussed. tal venous system. Therefore, anatomical resec-
tion of each segment or section is safe in terms of
Keywords hepatic function and oncologic safety. The right
anterior section consists of two segments, V and
Hepatocellular carcinoma · Sectionectomy VIII. In this chapter, the concept and technical
Anterior section · Glissonean approach details of both open and laparoscopic resections
Anatomical resection of right anterior sectionectomy are discussed.

Supplementary Information The online version con-

tains supplementary material available at https://doi.
org/10.1007/978-­981-­16-­1996-­0_8.

K. J. Kang (*) · K. S. Ahn

Division of Hepatobiliary and Pancreatic Surgery,
Department of Surgery, Keimyung University
Dongsan Hospital, Daegu, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 43

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_8
44 K. J. Kang and K. S. Ahn

tumor or multiple metastatic tumors, the extent of

resection should be increased similar to right
hemihepatectomy [1].

8.3 Preoperative Evaluation

Preoperative evaluation includes complete blood

count, coagulation profiles, and hepatic and renal
function tests. Above all, liver function is essen-
tial for single section resection according to the
resection criteria [2]. Functional assessment of
the remaining liver and evaluation of the extent of
cirrhosis should be conducted. A Child-Pugh-­
Fig. 8.1 Schematic diagram of the hepatic segments and
sections. Right anterior sections include segments 5 and 8 Turcotte score A is desirable, with a total biliru-
bin level <2 mg/dL and ICG R15 < 20%.
Determination of the extent of hepatic resection
8.2 Indications and the relationship between vasculature and the
and Contraindications volume of future liver remnant requires analysis
of not only the cross-sectional images but also
Resection of tumors located in the right anterior the coronary sections of the dynamic CT scan or
section requires adequate function of the hepatic contrast-enhanced magnetic resonance imaging
reservoir in terms of ICG R15 (<20%), prothrom- (MRI) using gadoxetate disodium (Primovist™).
bin time (INR < 1.3), and bilirubin level (<2 mg/ In addition, 3D reconstruction images are very
dL). Segmentectomy is feasible if the tumor is useful not only to increase the accuracy of resec-
located in one segment (5 or 8). Tumor confined tion margin and future liver remnant volume, but
to the right anterior section with moderate degree also to delineate anatomical structures (Fig. 8.2).
of hepatic cirrhosis without extending beyond the The mass should be located between the right and
right anterior section is a strong indication. If the mid-hepatic vein, ensuring that the tumor is
liver function is adequate, further resection not in contact with the hepatic veins. Tumor
including right hemihepatectomy is preferred for ­invasion or portal vein thrombosis over the resec-
good surgical outcome based on convenience and tion territory is not an indication for the right
oncologic safety. Otherwise, in case of large anterior sectionectomy [3].
8 Right Anterior Sectionectomy 45

Fig. 8.2 Reconstruction image using Synapse 3DⓇ sys- portal veins, hepatic arteries, and hepatic veins. (b)
tem created by Fujifilm®. The green-colored mass is a Extracted tumor, portal vein, and hepatic vein from
huge hemangioma. (a) Relationship between tumor mass, Fig. 8.2a
46 K. J. Kang and K. S. Ahn

8.4 Surgical Technique the anterior to ensure adequate exposure.

After completing the mobilization of the
8.4.1 Open Surgery right liver, the right hepatic vein is isolated
and Laparoscopy and covered with an umbilical tape if
possible.
(1) Positioning (5) Intraoperative ultrasonography (IOUS) of
For the open surgery, the patient is posi- the liver is used to delineate the vascular
tioned supine with left arm on the table anatomy and the relationship between the
besides the trunk and right arm held away to tumor and hepatic portal veins, to validate
maintain IV lines and monitor vital signs the findings of dynamic CT and MRI preop-
with an intra-arterial catheter by anesthesi- eratively. Ultrasonogram can be used to iden-
ologist. For laparoscopic surgery, lithotomy tify the trunk of the right hepatic vein towards
position is better for both the operator and the periphery and the relationship with the
assistants including photographer. A warm tumor. The same procedure can be applied
pad is used over the trunk except in the oper- for the mid-hepatic vein (Fig. 8.3). The bifur-
ation field. Deep vein thrombosis of the cation of the main portal vein into right and
lower limbs is prevented via intermittent left portal veins is then identified, and the
pneumatic compression. right anterior and posterior branches are
(2) Incision traced to determine the feeding portal vein
Depending on surgeon’s preference, the territory for resection, and also identify pos-
liver may be exposed for mobilization via sible tumor thrombus in the portal vein.
inverted “Y” shape (so-called Mercedes) (6) Cholecystectomy and encircling of the right
incision, bilateral subcostal incision or an anterior Glissonean pedicle
inverted “L” incision. Rarely, an upper mid- Cholecystectomy is followed by isolation
line incision is adopted, but it is inconvenient of the right main portal pedicle.
to adequately mobilize the right liver. A. The Glissonean approach. To dissect the
(3) Careful inspection and exploration of the right main portal pedicle, an extra-­
abdominal cavity Glissonean approach beginning at the
Even though exploration is less important upper border of the right main trunk is
currently than in the era before dynamic CT adopted without breaking the Glissonean
or MRI, careful inspection and palpation of sheath between right and left main por-
the entire intra-abdominal organs including tal pedicles. Next, a downward dissec-
pelvic cavity are used to identify extrahe- tion toward the right caudate lobe of the
patic metastasis, seeding or hidden tumor(s) liver is performed to break through the
before dissection around the liver. plane between portal pedicle and hepatic
(4) The hepatic suspensory ligaments including attachment (Fig. 8.4.) In this procedure,
ligamentum teres hepatis are cut initially, Yankauer suction tip enables dissection
followed by the falciform and coronary liga- and suctioning of minor hemorrhage,
ment and the bilateral triangular ligament. and combination with periosteal eleva-
The right liver is mobilized by dissection of tor to expose the dissecting plane
the right inferior hepatic peritoneal layer to between portal pedicle and the liver
enter the bare area to carefully divide the (Fig. 8.5).
right adrenal gland attached to the liver. When the plane is tunneled, the right
Next, proceeding along the retrohepatic IVC, portal pedicle is covered with umbilical
the IVC ligament is encountered in the tape, followed by the same procedure to
upward direction, and carefully divided divide the right anterior and posterior
without injury to the IVC. Upon completion pedicles and encircling with umbilical
of this procedure, the right liver is shifted to tapes individually. Test clamping of the
8 Right Anterior Sectionectomy 47

Fig. 8.3 Intraoperative ultrasonogram. (a) Tumor with portal and hepatic veins. (b) During hepatic transection, ultra-
sonogram reveals the relation between the tumor and transection plane to ensure adequate margin
48 K. J. Kang and K. S. Ahn

Fig. 8.4 The combination of Yankauer suction tip, periosteal elevator, and suction device facilitates the dissection of
the extra Glissonean capsule to encircle the Glissonean pedicle

may be weak in case of cirrhotic liver or

variation and cross feeding portal vein
branches. Therefore, the injection of
indigo carmine dye into the isolated por-
tal vein branch ensures discrete demarca-
tion, which is one of the advantages of
the individual isolation of the portal vein
Fig. 8.5 The Yankauer suction tip with periosteal [5].
elevator (7) Hepatic transection and division of the right
anterior portal pedicle
anterior portal pedicle with Bull-dog or The hepatic parenchyma is transected
small Satzinsky clamps ensures ischemic according to the demarcation line either right
demarcation on the hepatic surface of the or left, depending on the anatomical location
right anterior section, and marking of the and tumor size. Generally, transection to the
ischemic margin via electrocautery left of Cantlie line is preferable. The first
(Fig. 8.6). transection is facilitated by hanging maneu-
For laparoscopic approach, the lapa- ver resulting in less bleeding. The upper end
roscopic Goldfinger retractor or Endo of hanging rope lies between the RHV and
Mini-Retract™ is very useful (Fig. 8.7). MHV, and the lower end between the right
After partial dissection of the Glissonean and the left Glissonean pedicles. Injury of
pedicle both superior and inferior border the veins with intrahepatic portal pedicles
of the pedicle, the Goldfinger dissector or can be prevented in the peripheral area via
Endo Mini-Retract™ is inserted and electrocautery or electric energy devices up
encircled and hooked to the pedicle using to 2 cm in depth, and the CUSAⓇ is useful for
an umbilical tape [4]. The next step is the deeper areas. When the transection
similar to the open surgery. reaches the Glissonean pedicle of both
B. Individual Isolation of the Portal Vein planes, the right anterior portal pedicle is
Alternatively, the portal vein can be divided as far distally as possible to avoid
isolated by separating the Glissonean injury to the posterior or left portal pedicles
sheath remaining in the bile duct and using a vascular stapler TA™ (Fig. 8.8).
hepatic artery in the sheath, followed by Notably, when a rubber rope is used for
test clamping of the portal pedicle after hanging, the right posterior should not be
encircling the right anterior and posterior pulled in the transection of the vascular
portal branches, for the demarcation of TA. The right posterior bile duct is prone to
the intended sections. The demarcation injury during retraction of the right anterior
8 Right Anterior Sectionectomy 49

a b

Fig. 8.6 Test clamping of the right anterior Glissonean pedicle with Satzinsky clamp (a) and ischemic demarcation of
the right anterior section (b)

a b

Fig. 8.7 Encircling the Glissonean pedicle for laparos- Endo Mini-Retract 5 mm (Covidien); (b) EndoRetract
copy using Goldfinger retractor (a, b) and various instru- Maxi 10 mm; (c) Goldfinger dissector (Johnson and
ments for dissecting and encircling the pedicle (c) (a) Johnson)

pedicle using a vascular stapler. Injury to the tions of the main hepatic veins can be stopped
left duct is rare. Subsequent transections with 5-0 Prolene sutures or via light cauter-
after the division of the right anterior pedicle ization with bipolar cautery, especially dur-
are easy. ing laparoscopy. Finally, the right anterior
Further hepatic transection toward the section is removed.
root in addition to both right and mid-hepatic (8) Cut surface
veins can be performed whether or not it is The transected hepatic surface is inspected
exposed on the transection plane. Bleeding for bleeding and leakage of bile after hepatic
from the side holes or large-bored fenestra- resection. Hemostasis can be resolved using
50 K. J. Kang and K. S. Ahn

a b

Fig. 8.8 Final step in anterior sectionectomy. (a) The right anterior pedicle is cut using vascular TA™. (b) The cut
surface of the liver and the cut end of the right anterior portal pedicle

bipolar and monopolar electrosurgery and 5. During the transection down the right anterior
ligation of bleeding vessels with Prolene 5-0 portal pedicle close to the hilum, the anterior
sutures. Active topical hemostatic agents and portal pedicle was cut using vascular TA™ as
sealants such as Tachosil™ or fibrin glue can far peripheral as possible to avoid the right
be used for high-risk areas in subsequent posterior or the left bile duct.
bleeding or bile leakage. After lavage of the
peritoneal cavity with normal saline solution,
a drainage catheter is used to detect postop- 8.5 Complications
erative hemorrhage or bile leakage, and the
abdominal wall layer is closed. 8.5.1 Bleeding

Tips The cut surface is broader than in hemihepatec-

1. The Right anterior sectionectomy involves tomy because of the two transection faces. The
two methods: the Glissonean pedicle approach risk of hemorrhage or bile leakage during and
clamping the portal pedicle in the Glissonean after surgery can be reduced by maintaining the
sheath and individual isolation of the portal central venous pressure during hepatic transec-
veins. tion as low as possible.
2. Discrete ischemic demarcation of the transec-
tion line using the Glissonean pedicle
approach is facilitated by ensuring temporary 8.5.2 Bile Leakage
clamping of both portal vein and hepatic
artery together. The risk of bile duct injury or bile leakage is higher
3. For the Glissonean pedicle approach, combi- in central hepatectomies, central bisectionectomy, or
nation of Yankasuer’s tonsil suction device right anterior sectionectomy. Therefore, a careful
and periosteal elevator is very useful in dis- dissection of the hilar plate is essential. Transection
secting the Glissonean sheath in a bundle. of the anterior portal p­ edicle should be as distal as
Injury to the portal vein is prevented by pre- possible to prevent injury to the left or right posterior
serving the Glissonean membrane of the branch of the bile duct. Intraoperative cholangiogra-
sheath intact. phy should be performed to prevent unexpected bile
4. Goldfinger™ dissector is a good device for duct injury, whenever biliary anatomy is unclear.
laparoscopic Glissonean pedicle approach. Vascular TA is very useful to cut the pedicle.
8 Right Anterior Sectionectomy 51

8.5.3 Oncologic Safety References

It is critical to ensure adequate tumor-free mar- 1. Chouillard E, Cherqui D, Tayar C, et al. Anatomical
bi- and trisegmentectomies as alternatives to extensive
gins. The exposure of right and mid-hepatic veins liver resections. Ann Surg. 2003;238:29–34.
is not absolutely necessary. However, in case of 2. Makuuchi M, Kosuge T, Takayama T, Yamazaki S,
inadequate tumor-free margins, the procedure can Kakazu T, Miyagawa S, Kawasaki S. Surgery for small
be modified for further resection, including cen- liver cancers. Semin Surg Oncol. 1993;9:298–304.
3. Lillemoe KD, Jarnagin WR. Hepatobiliary &
tral bisectionectomy or right hemihepatectomy. Pancreatic Surgery. Philadelphia: Lippincott and
Wilkins; 2013.
4. Honda G, Karata M, Okuda Y, Kobayashi S, Sakamoto
8.6 Conclusion K, Takahashi K. Totally laparoscopic anatomical
hepatectomy exposing the major hepatic veins from
the root side: a case of right anterior sectorectoy. J
The right anterior sectionectomy is indicated for Gastrointest Surg. 2014;18:1379–80.
patients carrying tumors in the right anterior sec- 5. Ahn KS, Kang KJ, Park TJ, Kim YH, Lim TJ, Kwon
tion and with insufficient hepatic reservoir func- JH. Benefit of systematic segmentectomy of the hepa-
tocellular carcinoma; revisiting the dye injection
tion. Otherwise, the right hemihepatectomy is method for various portal vein branches. Ann Surg.
preferable due to oncologic safety, better anatom- 2013;258:1014–21.
ical incision and technical precision.
 Right Posterior Sectionectomy
9
Yang-Seok Koh

Abstract
9.1 Indications
Right posterior sectionectomy entails division
of the liver parenchyma following the right Tumors located in this section without invasion
hepatic vein. Two traditional methods for of the right hepatic vein and the right intrahepatic
inflow control including individual and the duct stone with or without intrahepatic duct stric-
Glissonian approaches were adopted. The tures are indications for this procedure.
plane of dissection is wider than the other
types of liver resection. The right hepatic vein
is often resected to secure the safety margin. 9.2 Technique

Keywords 9.2.1 Incision

Right posterior sectionectomy · Right hepatic
Reverse T incision, both subcostal incision, mid-
vein · Glissonian approach
line incision, right subcostal incision, and reverse
L incision are used.
Right posterior section includes the Couinaud
segments 6 and 7 [1]. The right posterior hepatic 9.2.2 Cholecystectomy
artery and the right posterior portal vein supply
blood, and the right posterior bile duct drains The gallbladder and cystic plate should be
bile. removed to facilitate inflow control.

9.2.3 Hepatic Hilum for Inflow

Control
Supplementary Information The online version con-
tains supplementary material available at https://doi. Two types of inflow control are performed.
org/10.1007/978-­981-­16-­1996-­0_9.
9.2.3.1 Individual Dissection
Y.-S. Koh (*) After cholecystectomy, the peritoneal incision of
Department of Surgery, Chonnam National the right side of hepatoduodenal ligament with trac-
University Medical School, Gwangju, South Korea tion of the cystic duct stump to anterior and leftward
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 53

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_9
54 Y.-S. Koh

Fig. 9.1 Individual inflow control

Fig. 9.2 Glissonian approach
is used to expose the right hepatic artery. Dissection
until the bifurcation of the right anterior and poste- 9.2.4 Liver Mobilization
rior hepatic arteries is followed by the isolation of
the right posterior hepatic artery (Fig. 9.1). The liver is retracted to the left by the assistant,
The right portal vein passes behind the right and right triangular and coronary ligament are
hepatic artery. Minor dissection up to the liver dissected until the right hepatic vein is exposed.
parenchyma exposes the right posterior portal The adrenal gland is easily exposed by upward
vein aided by the ligation of small portal branches traction of the liver anterior to the IVC, which in
to the caudate lobe. a few difficult cases prevent easy isolation, and
The right posterior hepatic duct is often ligated minor portion of the liver covering the adrenal
at the final stage of liver parenchyma division. gland is removed. Short hepatic veins are serially
divided from the caudal to the cephalad to fully
9.2.3.2 Glissonian Approach expose the right hepatic vein. Vessel taping of the
It is a rapid and easy approach to inflow control. right hepatic vein may be a preventive measure to
However, the risk of bleeding during the isolation avoid bleeding. A Penrose drain insertion
and the relative distal control of the Glisson com- between the right and middle hepatic vein is often
pared with the individual control should be borne used for hanging of the liver to facilitate paren-
in mind. chymal division and reduce bleeding.
In most cases, the posterior Glisson lies in the
Rouviere sulcus, whereas the anterior Glisson passes
posterior to the cystic plate. The entry point is 9.2.5 Parenchymal Division
between the cystic plate and the Rouviere sulcus,
and smooth circling around the Glisson using a The cutting is followed along the demarcation line.
right-angled clamp or similar instrument can be used Sutures on both the sides of the line may facilitate
to fully isolate the right posterior Glisson. Clamping tracts in opposite directions. CUSA and Kelly are
leads to pale posterior section and visible demarca- two main instruments for the division of the liver.
tion line. Umbilical taping of the right posterior Tubular structures and vessels during dissection
Glisson facilitates subsequent hanging (Fig. 9.2). should be ligated meticulously to prevent subse-
Minor bleeding from the hilar plate may be quent bleeding or bile leak. The right hepatic vein
avoided using hemostatic materials such as is the land mark between the right anterior and pos-
Surgicell® or bipolar cauterization. When the terior sections, and dissection should be continued
Glisson capsule is thick and does not encircle in to expose fully the point of intersection of the right
one motion, the Pringle maneuver is often per- hepatic vein and the IVC (Fig. 9.3).
formed to decrease the blood flow.
9 Right Posterior Sectionectomy 55

a b

Fig. 9.3 RHV exposure during conventional right posterior sectionectomy (a) and during extended right posterior
sectionectomy (b)

9.2.6 Cut Surface and Drain Reference

1. Couinaud C. Liver anatomy: portal (and suprahepatic)
When the specimen is extracted, the cut surface or biliary segmentation. Dig Surg. 1999;16(6):459−67.
should be cautiously examined for possible bleed- https://doi.org/10.1159/000018770. PMID: 10805544.
ing and bile leakage. Hemostatic agents or materi-
als are sprayed and placed on the cut surface to
prevent bleeding from the right adrenal gland.
One or two closed suction drains are placed.
 S4 Segmentectomy
With or Without Resection 10
of Ventral Area of Right Anterior
Section

Yang Won Nah

Abstract segment (area) of the right anterior section.

Tumor adherent to the middle hepatic vein is a
In this manuscript and video, I will describe
good indication for this parenchyma-sparing
the liver resection procedure entailing resec-
resection.
tion of the ventral branches of the right ante-
rior Glisson pedicle and the Glisson pedicles
Keywords
to segment 4. In this procedure, the left resec-
tion margin corresponds to the umbilical fis- Liver anatomy · Liver resection
sure and the right resection margin the right Segmentectomy · Parenchyma-sparing
anterior Glisson pedicle. It is difficult to delin- resection · Hepatocellular carcinoma · Right
eate the right resection margin, which is the anterior section · Dorsal area · Ventral area
core of this surgery. In the final step of the Medial segmentectomy
operation, the middle hepatic vein is divided
at its junction with the left hepatic vein. This
Anatomical liver resections in which the left
operation is based on the anatomical division
resection margin is in line with the falciform
of the portal basin of the right anterior section
ligament include medial segmentectomy (seg-
into ventral and dorsal areas, unlike the tradi-
mentectomy 4), central bisectionectomy (seg-
tional Couinaud’s segmental anatomy, which
mentectomy 4, 5, 8), and right trisectionectomy
divides the basin of the right anterior portal
(segmentectomy 4, 5, 6, 7, 8) (Table 10.1). The
vein into superior and inferior segments. In
left resection margin is visible by connecting the
the absence of a specific term describing this
falciform ligament and the umbilical fissure. In
procedure, I have arbitrarily designated it as
case of medial segmentectomy, the right resec-
central bisegmentectomy in this manuscript.
tion margin on the Cantlie line is not discernible
Bisegments here mean segment 4 and ventral
on the surface of the liver. However, ligation of
Glisson pedicles to the medial segment leads to
Supplementary Information The online version con-
tains supplementary material available at https://doi. discoloration of the medial segment, which
org/10.1007/978-­981-­16-­1996-­0_10. reveals the Cantlie line clearly (Fig. 10.1).
Therefore, anatomical medial segmentectomy
Y. W. Nah (*) can be performed similar to other Glissonian
Department of Surgery, Ulsan University Hospital, approaches.
University of Ulsan College of Medicine, Anatomical hepatic resection is traditionally
Ulsan, South Korea based on Couinaud’s concept of liver anatomy
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 57

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_10
58 Y. W. Nah

Table 10.1 Anatomical liver resections where the left ing ventro-dorsal bifurcation or trifurcation have
resection margin is aligned with the falciform ligament
been reported [2–6].
and umbilical fissure
In this manuscript and video, I will describe
Major
Important hepatic
the resection procedure in which the territory
structure along vein(s) supplied by the Glisson pedicles to segment 4
the right being and the ventral branches of the right anterior
Surgical procedure resection margin divided Glisson pedicle are resected. In this procedure,
According to Couinaud’s anatomy the left resection margin corresponds to the
Left medial MHV None
segmentectomy (left
umbilical fissure, and the right resection margin
medial sectionectomy) represents the right anterior Glisson pedicle
Central RHV MHV (Fig. 10.2). In the final step of the operation,
bisectionectomy middle hepatic vein was divided at its junction
Right trisectionectomy None MHV, with the left hepatic vein. This operation is based
RHV
on the anatomical division of the portal basin of
According to Hjortsjo’s anatomy
the right anterior section into ventral and dorsal
Central Right anterior MHV
bisegmentectomya Glisson areas, unlike the traditional Couinaud’s segmen-
pedicle tal anatomy, which divides the basin of the right
MHV middle hepatic vein, RHV right hepatic vein anterior portal vein into superior and inferior
a
Resection of segment 4 and ventral area (segment) of segments.
right anterior section In the absence of a specific term defining this
procedure, I have arbitrarily designated it as cen-
tral bisegmentectomy involving segment 4 and
ventral segment (area) of right anterior section.
The procedure is completely different from the
central bisectionectomy, because the trunk and
dorsal branches of the right anterior Glisson ped-
icle are preserved in this central bisegmentec-
tomy procedure. Particularly, it is difficult to
understand and identify the right resection mar-
gin and is the core of this surgery. In this proce-

RVP
P4

P3

RDP
RAP
P2
RPP
Fig. 10.1 Left medial segmentectomy. The right resec-
tion margin is visible by dividing the respective Glisson
cords. It is compatible with the Cantlie line (modified IVC

from reference [3, 7])

1. RDP, right dorsal portal vein
2. RPP, right posterior portal vein
grounded in portal vein ramification (Table 10.1) 3. RVP, right ventral portal vein

[1]. According to Couinaud’s classification, the

right anterior portal vein is divided cranio-­ Fig. 10.2 Central bisegmentectomy (resection of seg-
ment IV and ventral area of the right anterior section). The
caudally into superior (segment 8) and inferior right resection margin is compatible with the right ante-
(segment 5) portal branches. Recently, other pat- rior Glisson pedicle. Its ventral branches are divided
terns of right anterior portal ramification includ- (modified from reference [3])
10 S4 Segmentectomy With or Without Resection of Ventral Area of Right Anterior Section 59

dure, the left and right hepatic veins are preserved, gery. Therefore, it is desirable to acquire ultra-
and the middle hepatic vein is amputated as men- sound images before surgery when the tumor is
tioned before (Table 10.1). Tumor adherent to the located deep inside the liver. If the tumor location
middle hepatic vein is a good indication for this is consistent with the results of preoperative
parenchyma-sparing resection. In this study, the imaging, the location is marked by tattooing at
focus is on surgical techniques alone. the liver surface with electrocautery.

10.1 Surgical Procedures 10.1.4 Cholecystectomy

10.1.1 Patient Position, Incision Cholecystectomy is essential for the left medial
and Peritoneal Exploration segmentectomy or central bisegmentectomy.
Once the gallbladder is removed, the base of the
Abdominal incision is based on the general prin- right anterior Glisson pedicle can be exposed
ciples of open surgery based on adequate room from the hilar plate after dividing the cystic plate.
for maneuver surgically. An inverted L-shaped
incision is preferred. Upper midline incision from
the xiphoid process to just above the navel was 10.1.5 Hepatectomy
made and extended transversely to the right at the
bottom of the incision, to avoid left abdominal Generally, liver transection is initiated from the
incision and thereby reduce pain in the left abdo- left resection margin, which facilitates the identifi-
men, and thus reduce pulmonary complications. cation of landmarks for resection, including the
falciform ligament along the superior liver surface
and umbilical fissure along the inferior liver sur-
10.1.2 Mobilization of the Liver face. The junction between the middle and left
hepatic vein is rather superficial and easy to
The falciform ligament is separated from the expose.
abdominal wall, and the round ligament is ligated, Ligation of Glisson pedicles to medial segment
cut, and held with Kelly forceps for traction. The is performed along the right border of the umbili-
major hepatic veins are exposed at the area of cal fissure. The liver parenchyma was transected
contact between the falciform ligament and the mainly using the Kelly clamp crushing method.
diaphragm. The root of middle hepatic vein is The Cavitron Ultrasonic Surgical Aspirator
localized. Usually, the left coronary and triangu- (CUSA) is often used to separate large Glisson
lar ligaments are not incised. However, the right cords or hepatic veins from the parenchyma.
coronary and triangular ligaments are cut so that
the right liver can be easily grasped. Most often, 10.1.5.1 Left Resection Margin
detachment of the liver from the inferior vena The line connecting the falciform ligament and
cava is not necessary during medial segmentec- the umbilical fissure, which can be seen with the
tomy or central bisegmentectomy. naked eye from the outside, becomes the left
resection margin. A couple of small superficial
Glisson cords that run from the tip of umbilical
10.1.3 Localization of the Tumor portion to the S4b can be easily isolated after
dividing the superficial liver tissue partially
Adequate mobilization of the liver facilitates between S3 and S4. The Glisson cords were
tumor localization. When a small tumor is located ligated and divided aided by traction of the round
deep inside the liver parenchyma, it is difficult to ligament aids (Fig. 10.3).
palpate manually. In this case, the location of the Usually, one to two large portal branches to
tumor is detected via ultrasonography during sur- segment 4b run from the upper area of the umbili-
60 Y. W. Nah

Fig. 10.3 Intraoperative view of the Glisson pedicles to Fig. 10.4 Intraoperative view of the Glisson pedicles to
segment IV. There are several Glisson pedicles to the seg- segment IV. Three large Glisson pedicles supply the seg-
ment IV (yellow taped) ment IV (yellow taped) after division of three superficial
small branches. The lowest one (arrow) is the branch to
segment IVa

cal portion in the left portal vein, and a branch to

segment 4a originates from the lower area of anatomical resection. It can be performed by con-
umbilical portion. These portal branches are tinuing the peeling of the hilar plate off the liver
grouped with arteries and bile ducts to form the parenchyma in the direction from G4a to the
Glisson cord and batch-ligated and divided right. A large right anterior Glisson pedicle is
(Fig. 10.4). The parenchyma is further transected encountered at the right end of the transverse por-
toward the direction of the middle hepatic vein. tion. Further dissection exposes the origin of
The middle hepatic vein is exposed in the last right anterior Glisson pedicle by 180° (Fig. 10.5).
course of the left resection, and if possible, a tape The direction of dissection is altered by follow-
is hung over the middle hepatic vein after full ing the anterior Glisson pedicle. Thus, the direc-
exposure. tion of liver transection is from the bottom to the
top, at the inferior surface of the liver.
10.1.5.2 Right Resection Margin Projecting an imaginary line toward the liver
Medial Segmentectomy edge following the direction of the exposed right
Segment 4 will be demarcated clearly by dividing anterior Glisson pedicle leads to the origin of the
the respective Glisson cords. Resection of seg- right resection at the liver surface, which is
ment 4 is completed by dissecting the liver paren- located in Couinaud’s segment 5. The extension
chyma along the discolored line, which is line from this point to the right edge of the middle
compatible with the Cantlie line and preserving hepatic vein represents the right resection mar-
the middle hepatic vein. During transection of the gin, which is marked with electrocautery on the
liver parenchyma along the direction of the mid- liver surface.
dle hepatic vein, several branches of the hepatic Subsequently, the liver parenchyma is tran-
vein running from the medial segment to the mid- sected along the electrocautery mark from the
dle hepatic vein are divided. superior surface of the liver toward the right ante-
rior Glisson pedicle until the pedicle is exposed
Central Bisegmentectomy 180°. Branches from the right anterior Glisson
In the case of central bisegmentectomy (resection pedicle to the ventral or leftward direction are
of medial segment and ventral area of right ante- ligated and cut in turn (Fig. 10.6). Usually, 2–3
rior section), the identification of the right ante- large branches are ligated, and these are the ven-
rior Glisson pedicle is the first step for accurate tral branches of right anterior Glisson pedicle.
10 S4 Segmentectomy With or Without Resection of Ventral Area of Right Anterior Section 61

Hilar plate

Fig. 10.5 The right anterior Glisson pedicle can be iden- Fig. 10.7 View after central bisegmentectomy (resection
tified via rightward dissection at the liver hilum along the of segment IV and ventral area of right anterior section).
right Glisson pedicle Note the ventral branches of the anterior Glisson pedicle
(arrows, Hem-O-Locked) and suture-closed stump of
middle hepatic vein (arrowheads)

10.1.6 Hemostasis, Drainage,

and Closure

The principles of general liver resection should

be followed. A meticulous hemostasis cannot be
overemphasized. I use two negative pressure
drain tubes: one drain tube is placed in the right
sub-diaphragmatic space and the other in the
Morrison pouch.

Fig. 10.6 Ventral branches (white arrows) from the ante-

rior Glisson pedicle (yellow arrows) are being ligated.
10.2 Precautions for Surgery
Glisson pedicles to segment IV (blue arrows) are already
clipped and divided 10.2.1 Bleeding

Blood loss is one of the most important factors

The hepatic vein branch from Couinaud seg- influencing morbidity after liver resection.
ment 8 to the middle hepatic vein emerges along Blocking inflow of blood by the Pringle maneu-
the parenchymal transection cephalad. It may be ver is an effective way to reduce bleeding during
preserved and followed to the middle hepatic liver transection. In addition, since the massive
vein, or ligated and divided according to the rela- hemorrhage during liver resection usually origi-
tionship with the tumor. Upon completion of the nates in the hepatic vein, it is important to main-
parenchymal transection, only the middle hepatic tain the central venous pressure low, usually
vein remains, which is clamped and divided. The below 5 mmHg. Bleeding from the hepatic vein
specimen is removed. The middle hepatic vein branch can be stopped, at least temporarily, sim-
stump is closed manually with a 4/0 Prolene ply using finger pressure. Therefore, in case of
suture (Fig. 10.7). The middle hepatic vein can be invisible bleeding, direct suture of the bleeding
managed with a vascular stapler. vessel in a pool of blood must be avoided, and
62 Y. W. Nah

instead, light finger pressure should be used at the liver until the end but leave behind residual
the bleeding point for 1–3 min until the origin of liver tissue at the end of crushing.
bleeding is visible and easily controlled.
Intra-hepatic anatomy is also important in Acknowledgments I appreciate Drs. Park
reducing bleeding during liver resection. For Hyung-woo and Yoon Jong-hee of Ulsan
example, if the location of the hepatic veins can University Hospital for organizing and editing
be predicted during parenchymal transection, this manuscript and video.
the bleeding can be managed effectively. A
thorough preoperative imaging analysis is
essential along with considerable surgical
experience. References
1. Strasberg SM. Nomenclature of hepatic anatomy and
resections: a review of the Brisbane 2000 system. J
10.2.2 Tips for Liver Parenchymal Hepato-Biliary-Pancreat Surg. 2005;12(5):351–5.
Transection 2. Kogure K, Kuwano H, Fujimaki N, et al. Reproposal for
Hjortsjo’s segmental anatomy on the anterior segment
Excessive pulling of the liver bilaterally during in human liver. Arch Surg. 2002;137(10):1118–24.
3. Cho A, Okazumi S, Miyazawa Y, et al. Proposal for a
surgery can tear the blood vessels. If the Kelly reclassification of liver based on portal ramifications.
clamp crushing method is used, it is better to Am J Surg. 2005;189(2):195–9.
reduce the traction strength during crushing. It is 4. Fasel JH, Schenk A. Concepts for liver segment classi-
necessary to adjust the power of crushing accord- fication: neither old ones nor new ones, but a compre-
hensive one. J Clin Imaging Sci. 2013;3:48–54.
ing to the degree of liver fibrosis in order to 5. Fujimoto J, Hai S, Hirano T, et al. Anatomic liver
reduce bleeding and shorten the transection time resection of right paramedian sector: ventral and
of the liver. Substantial liver fibrosis can result in dorsal resection. J Hepatobiliary Pancreat Sci.
tearing of blood vessels upon soft crushing 2015;22(7):538–45.
6. Cazauran JB, Pâris L, Rousset P, et al. Anatomy
because the fibrotic tissue is stronger than the of the right anterior sector of the liver and its clini-
vessel wall. Instead, bold crushing may be a strat- cal implications in surgery. J Gastrointest Surg.
egy to reduce the transection time in this case 2018;22(10):1819–31.
rather than soft crushing, especially for cirrhotic 7. Yamamoto M, Katagiri S, Ariizumi S, et al. Tips for
anatomical hepatectomy for hepatocellular carcinoma
liver. The degree of bold crushing should be by the Glissonean pedicle approach. J Hepatobiliary
guided by experience. A precaution: do not crush Pancreat Sci. 2014;21:E53–E56.
 S5 & S6 Segmentectomy
11
Soon-Chan Hong and Chi-Young Jeong

Abstract
11.1 Method
With respect to bisegmentectomy (s4 and s5),
performing accurate anatomical hepatic resec- After cholecystectomy is performed, liver mobi-
tion seems to be rare, and more importantly, it lization is conducted up to the right hepatic vein.
seems necessary to pay more attention to Then, with laparoscopic ultrasound, the middle
ensuring a sufficient resection margin for the hepatic vein, which borders segment IV, is
tumor and selecting the liver resection range checked, and the right boundary line is marked
that minimizes venous congestion or an isch- with electrocautery. Alternatively, a right-side
emic injury after surgery. Recently, laparo- Glissonean approach is used to temporarily ligate
scopic bisegmentectomy (s4 and s5) has been the right Glisson to check the boundary between
performed frequently due to the development segments IV and V along the ischemic line
of techniques and instruments for laparo- (Fig. 11.1).
scopic liver resection. This chapter describes In the case of open surgery, the boundary
laparoscopic liver resection. between segments V and VI can be confirmed
based on counterstaining identification of P8 and
Keywords ultrasonically guided puncture and injection of
the dye into P6. However, in cases of laparo-
Anatomical segmentectomy scopic surgery, which is based on the virtual line
Bisegmentectomy · Laparoscopy · Segment 5 of the horizontal plane of the left and right
Segment 6 branches of the portal vein, it is reasonable to
select the resection line considering the position
of the tumor. After confirming the tumor with
laparoscopic ultrasound, the resection line is
secured and marked with electrocautery. For
counter traction, stay suturing can be performed.
Supplementary Information The online version con- For the pringle maneuver, U-tape is placed in the
tains supplementary material available at https://doi.
org/10.1007/978-­981-­16-­1996-­0_11. hepatoduodenal ligament, and the laparoscopic
endo-bulldog can be used to save the trocar port

S.-C. Hong · C.-Y. Jeong (*)

Department of Surgery, Gyeongsang National
University School of Medicine, Jinju, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 63

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_11
64 S.-C. Hong and C.-Y. Jeong

During liver resection, even if the vessel is small,

careful ligation is advantageous to maintain a
clean field of view and a good resection surface.
At this point, if the middle hepatic vein is encoun-
tered, it is dissected with CUSA® suctioning and
then ligated. In the case of liver cirrhosis, CUSA®
becomes less effective; therefore, liver resection
can be performed with the crush clamping tech-
nique using LigaSure®. When using a LigaSure®,
activating it by opening and closing the jaw using
the foot switch and not completely closing it can
ligate thick blood vessels and bile ducts, while
complete closure of the jaw can stop bleeding. In
case of an increase in the amount of bleeding or
Fig. 11.1 Couinaud’s liver segments 5 and 6
difficulties in continuing with CUSA®, it can be
a useful technique to try. After resection between
for clamping. At this time, it is safer and more segments IV and V, the operator moves to the left
effective to clamp the hepatoduodenal ligament side of the patient and performs resection between
on the patient’s left side. Liver resection starts at segments VI and VII. At this time, if a branch of
the boundary with segment IV, and the operator the thick middle hepatic vein drains segment VI
stands between the legs of the patient. A liver alone, it is ligated and excised. When the resec-
resection of 1 cm from the surface is performed tion between segments VI and VII proceeds, trac-
with a harmonic scalpel at the border between tion and hanging are performed as the U-tube is
segments IV and V, followed by liver resection hung by the groove of the resected liver paren-
with a laparoscopic cavitron ultrasonic surgical chyma (sling suspension technique), and the lat-
aspirator (CUSA®). Here, if counter traction is eral posterior parenchyma of segment VI is
not properly performed, it becomes difficult to brought close to the eye. After completion of
use CUSA®; therefore, the patient’s position is liver resection, bleeding or bile leakage in the
tilted toward the left side to use gravity, and liver resection margin is checked and fibrin glue
counter traction is performed using stay sutures. is applied.
 S7 & S8 Segmentectomy
12
Hee Jung Wang and Sung Yeon Hong

Abstract 12.1 Introduction

Resection of liver tumors located in Couinaud
In segmental anatomy, liver segments 7 and 8 are
segments 7 and 8 is challenging due to their
located at the superior aspect of the liver with no
intricate location and difficulty of identifying
noticeable surface structure to outline their bor-
feeding Glissonean pedicles. Various surgical
ders. Moreover, their segmental portal branches
approaches can be employed case by case
are deeply situated thereby rendering difficulties
according to individual segmental anatomy of
in ligation before parenchymal transection.
the patient. In this chapter, the role of preop-
Segment 7, alongside segment 6, forms the
erative 3D imaging and the technique of ana-
posterior-­right lateral portion of the liver stretch-
tomical liver resection for tumors located in
ing up to the right border of the spinal body and
segments 7 and 8 are discussed.
medially neighboring the inferior vena cava.
Internally, segment 7 is located at the right poste-
Keywords
rior aspect of the right hepatic vein or right portal
Hepatocellular carcinoma · Sectionectomy fissure. The borderline between segments 7 and 6
Anterior section · Glissonean approach is usually a coronal plane. However, it is possible
Anatomical resection · Segmentectomy 7 and 8 to identify it by ischemic demarcation after the
ligation of the segment 7 branch or by intraopera-
tive ultrasound during surgery. The boundaries of
segment 8 are at the main portal fissure toward
the left side and the right portal fissure toward the
right side. The posterior border of segment 8 is
Supplementary Information The online version con- the superior leaf of the right coronary ligament,
tains supplementary material available at https://doi. and the anterior border is roughly at the coronal
org/10.1007/978-­981-­16-­1996-­0_12. plane of the porta hepatis. Internally, segment 8 is
located at the anterior-superior aspect of right
H. J. Wang (*)
Department of Surgery, Inje University Haeundae and middle hepatic veins (RHV and MHV), and
Paik Hospital, Busan, Korea the inferior vena cava (IVC) is not found at the
e-mail: [email protected] border. However, IVC can be exposed at the
S. Y. Hong superior part of the posterior border where a con-
Division of Hepatobiliary Surgery and Liver fluence of RHV and MHV is seen (Fig. 12.1).
Transplantation, Department of Surgery, Ajou
University School of Medicine, Suwon, Korea

© Springer Nature Singapore Pte Ltd. 2023 65

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_12
66 H. J. Wang and S. Y. Hong

12.4 Comprehending 3D Image

and its Necessity in Planning
the Surgery

Couinaud’s eight-segment scheme, despite its

usefulness and simplicity, can serve as a dogma
that divides the liver in a man-made fashion. In
general, the liver has constant first and second-­
order inflow branches that divide the organ into
two hemilivers and three sections which have a
watershed plane where the hepatic veins are
located. However, this schema of anatomical
description renders or even precludes inflow-­
oriented anatomical liver resection as it neglects
Fig. 12.1 Schema of Couinaud 8 segments of the liver
the variation of inflow vessels in terms of number
and sliding of their origins. In the next section, the
12.2 Indications variation in inflow in the right hemiliver by the
and Contraindications present author’s experience in cadaveric liver dis-
section and 3D image analysis will be discussed.
Segmentectomy 7 and 8 can be performed in Our institution adopted Synapse 3D (Fuji film)
selected patients with liver tumors located at the in 2016, and we analyzed the variation in third-
superior aspect (dome) of the liver and with com- order inflow branches to the right anterior and pos-
promised liver function to permit a larger extent terior sections (RAS and RPS) in 96 liver donors
of hepatic resection. For successful surgery, the from 2017 to 2018. The result showed that the por-
tumor must be confined to the corresponding tal pedicles to the RAS have four different branch-
liver segment, and the segmental anatomy must ing types; A-D. A cranio-caudal type or type A is
not have such anatomical variations as severe when the third-order branch structure corresponds
sliding of origin of the Glissonean pedicles. to the Couinaud’s segments 5 and 8 anatomies and
Gross tumor thrombosis in the portal vein or comprised 45.8% (44) of the cases. Ventral-dorsal
hepatic vein is a contraindication to the surgery. type or type B (13, 13.5%) is responsible for the
segments 5 and 8 of which are supplied by two or
more fourth-­order branches from a different third-
12.3 Preoperative Assessment order branch. A radial type or type C (33, 34.4%)
and Designing the Liver is when there are multiple or usually more than
Resection four third-order branches present. In this case, seg-
ments 5 and 8 cannot be distinguished. In the slid-
Patients with hepatocellular carcinoma confined to den type or type D (6, 6.3%), the third- or
the corresponding liver segments with preserved fourth-order branches of the RAS and RPS tra-
liver function (i.e., no ascites, serum bilirubin less verse to other territories (Fig. 12.2).
than 1.0 mg/dl, and ICG-R15% less than 20–25%) The RPS, likewise, has four distinct anatomi-
and no severe systemic disease are indicated for cal entities. Type A is whereby the right posterior
this type of liver segmentectomy. Abdominal CT portal pedicle has a common trunk (a second-­
scans and MRIs are used to assess the anatomical order branch) and further gives its branches (two)
structure and its relation to tumors. Recently, to each segment 6 and 7, and comprised 34.4%
three-dimensional depiction of the liver segmental (33) of the cases. In type B, similarly, the right
anatomy has become possible, and a more delicate posterior section pedicles branch to each segment
approach in the form of navigation, according to but in the absence of a common trunk (14,
individual liver anatomy has been practised. 14.6%). The right posterior portal pedicle in type
12 S7 & S8 Segmentectomy 67

a b

c d

Fig. 12.2 (a) Classic cranio-caudal type (b) ventral-dorsal type variation (c) radial type variation (d) variation with
third or fourth-order branches of RAS and RPS traversing to other territories

C runs through the liver parenchyma toward seg- 12.5.2 The Procedure of Anatomical
ment 7 and gives multiple branches to segment 6 Resection of Segments 7
(43 cases, 44.8%). Lastly, type D is likewise of and 8
type D of RAS variation.
In conclusion, a strictly controlled anatomical 12.5.2.1 Segmentectomy 8
resection of segments 7 and 8 can be performed 1. Type A Branching Pattern of RAS on
in only 48.0% (A type of RPS variant) and 45.8% Preoperative 3D Image Analysis
(A type of RAS variant) of all the cases, respec- In type A RAS portal pedicle anatomy, two
tively. However, given that 3D CT image recon- approaches can be undertaken. The first
struction is available, a higher success rate of approach is known as Makuuchi’s method [1],
anatomical resection can be achieved by design- whereby ultrasound-guided indocyanine
ing the resection plane according to the individ- green dye injection to a single P8 is performed
ual anatomy. Otherwise, a larger extent of liver for liver surface staining of segment 8
resection or nonanatomical wedge resection must (Fig. 12.3). Cantlie’s line and a transverse
be selected in patients with variant anatomy. liver transection along the demarcation line
are the first steps to find a single P8.
Subsequently, P8 is ligated and liver paren-
12.5 Operative Technique chymal transection is continued thereby
exposing the ventral portion of the RHV. A
12.5.1 Laparotomy and Liver specimen ­containing segment 8 can thus be
Mobilization taken out after completion of liver dissection
to the IVC at the superior border. When P8
A right subcostal incision followed by a midline puncture is unpliant, a second method known
incision or a Hockey-stick incision is generally as Takasaki’s approach can be attempted. In
preferred. Falciform ligament and coronary liga- this procedure, the main right portal pedicle is
ment are dissected up to the IVC. Cholecystectomy temporarily clamped to induce ischemic
is performed subsequently and a nelaton catheter demarcation to the right hemiliver. The
is encircled around the hepaticoduodenal liga- demarcation line or interlobar plane is dis-
ment for Pringle maneuver. sected and a superior-ventral portion of the
68 H. J. Wang and S. Y. Hong

Fig. 12.3 Delineation of segment 8 by US-guided ICG dye injection. (Makuuchi’s method)

main portal fissure is found. Then, the P8 is order branches can be called anatomical resec-
ligated at its root. Ischemic demarcation of tion. If the ventral cone unit of RAS encompasses
segment 8 can be seen and the process after- the tumor, resecting the territory of the corre-
ward is identical to Makuuchi’s method. The sponding third-order branch can be a more ideal
difference between the two procedures is that approach as an anatomical resection.
the operator can see the anterior and right bor- In the case of irregular branching (more
der of segment 8 before liver parenchymal than 4) of the third-order branches or type C
transection in Makuuchi’s method, whereas in branching pattern of RAS, segmentectomy 8
Takasaki’s method, only the left border can be can be a challenging task. In such a case,
noticed before commencing the liver transec- Makuuchi’s approach is not recommended.
tion. If 3D images are available and if there is Likewise, liver parenchymal transection can
only one P8, the two methods are considered be carried out by finding and ligating multiple
as equally simple and feasible. P8s in the ventral to the dorsal direction. Since
2. Type B or C Branching Type of RAS on it is not likely to be able to ligate all P8s at
Preoperative 3D Image Analysis. their roots, the success rate of anatomical
In type B RAS branching pattern, the third-­ resection is low. If the operator is determined
order branches of the right anterior portal vein to perform an anatomical resection, the trans-
spread in the ventral-dorsal direction. The P8s fissural approach can be used as an alterna-
consist of two or more fourth-order branches tive. As a first step, the hilar plate is lowered
arising from the ventral and dorsal third-order by blunt dissection, and the right Glissonean
branches. In such cases, the success rate of pedicle is encircled with a nelaton tube. The
Makuuchi’s approach is low. Hence, Takasaki’s ischemic demarcation of the right hemiliver
approach is preferred. The right portal pedicle is can be observed by temporary clamping. The
temporarily clamped and the superior-­ventral demarcation line is the main portal fissure.
portion of the main portal fissure is dissected Subsequently, transection of the liver paren-
along the ischemic demarcation line. The ven- chyma through the main portal fissure using
tral branches of segment 8 are subsequently CUSA or a Kelly clamp crushing is carried
ligated and the liver parenchymal transection is out until the dissection reaches the hilar plate.
continued posteriorly to find the dorsal Afterward, the dissection plane is tilted
branches. After ligation of the dorsal branches, toward the right side following the right ante-
segment 8 is demarcated and the operator can rior portal pedicle to find P5 and P8 within
complete segmentectomy 8. However, it 2 cm from the hilar plate. Temporary clamp-
remains controversial whether performing a ing of P8 allows visualizing the segment 8 ter-
segmentectomy by ligating multiple fourth- ritory at the liver surface. The ischemic
12 S7 & S8 Segmentectomy 69

demarcation of segment 8 is marked at the attempting Takasaki’s procedure. A consider-

surface using bovie. Parenchymal transection able amount of hemorrhage can result since
is continued toward the right side until RHV hemostasis becomes difficult. Even so, the suc-
is exposed. Following the RHV, the dissection cess rate of anatomical resection remains low.
proceeds to suprahepatic IVC. Meanwhile, At the time when the 3D image was not avail-
dissection of the connective tissue to the right-­ able in our institution, I managed to perform
hand side of the anterior surface of the IVC segmentectomy 8 by transfissural approach
allows visualization of the RHV trunk. An with a success rate of 80%. This approach
additional parenchymal dissection parallel to allows the visualization of P8 root in most of
the RHV separates segment 8 from the liver. the cases, but it is an invasive procedure. The
After extraction of the specimen, the cut-­ detailed procedure is described in section ②.
surface of the liver is coagulated with an argon
beam laser or a bipolar coagulator. Finally, the 12.5.2.2 Segmentectomy 7
surgeon finishes the procedure by reassuring Anatomical resection of segment 7 is the least
hemostasis with a tachocomb seal or fibrin successful procedure of all the segmentectomies,
glue spray (Fig. 12.4). although the definition of the anatomical resec-
3. Type D Branching Type of RAS on tion may vary. Two approaches are used in our
Preoperative 3D Image Analysis. institution. The first approach is Takasaki’s
Anatomical resection is rarely achievable in approach [2] where the Glisson sheath is lowered
type D variant anatomy of the RAS. A wedge from the hilar plate and the right posterior pedicle
resection is rather convenient. However, is separated. Temporary clamping of the right
Takasaki’s procedure or main portal fissure posterior pedicle induces ischemic demarcation
approach can be applied in the case of the ante- of the RPS thereby revealing the right portal fis-
rior section dominant type. On the contrary, in sure. The superior aspect of the right portal fis-
the case of posterior section dominant type, sure is dissected and the surgeon finds the P7.
wedge resection is preferred unless small con- Ligation of P7 follows and further dissection
tracted segment 8 can confine a small tumor. along the RHV completes segmentectomy 7
4. Preoperative 3D Image is Not Available. (Fig. 12.5). The second approach is the
Using a 2-dimensional study only limits the
success rate of Makuuchi’s procedure when
conducting anatomical resection. Also,
unawareness about P8’s anatomical variation
may consume an excess amount of parenchy-
mal dissection to find the root of P8 when

Fig. 12.5 Takasaki approach. Delineation of segment 7

by detecting and clamping the root of S7 pedicle through
Fig. 12.4 The operative field after monosegmentectomy the parenchymal dissection on the dorsal 2/3 of the right
of segment 8 using transfissural approach portal fissure
70 H. J. Wang and S. Y. Hong

ultrasound-­guided method. It is used when find-

ing P7 by the above-mentioned approach is unpli-
ant or in case of severe liver fibrosis. An
ultrasound probe is applied to half the area of the
right portal fissure in search of the bifurcation
point of P6 and P7. Parenchymal transection is
performed along the plane perpendicular to the
right portal fissure. After ligation of P7, the dis-
section line follows RHV. Despite the satisfac-
tory surgery, the second approach can be
criticized for not following the strict rule of ana-
tomical resection (Fig. 12.6).

References
Fig. 12.6 Lateral approach. Delineation of segment 7 by
identifying and clamping the root of S7 pedicle through 1. Makuuchi M, Hasegawa H, Yamazaki S. Ultrasonically
the parenchymal dissection from right lateral to medical guided subsegmentectomy. Surg Gynecol Obstet.
direction of the coronary plane. We can decide this plane 1985;161:346–50.
by detecting the confluence of S6 and S7 Glisson pedicles 2. Takasaki K. Glissonean pedicle transaction method for
using intraoperative ultrasonography hepatic resection. 1st ed. Japan: Springer; 2007.
 Laparoscopic Left
Hemihepatectomy 13
Ki-Hun Kim and Hwui-Dong Cho

Abstract
13.1 Definition
Left hemihepatectomy refers to the resection
of segments II, III, and IV of the liver accord- Left hemihepatectomy refers to the resection of
ing to the Couinaud classification. If the tumor segments II, III, and IV of the liver without the
is not too close to the liver hilum or major ves- middle vein according to the Couinaud classifica-
sels such as IVC and middle hepatic vein, the tion, and resection with the middle vein is called
indication of laparoscopic left hemihepatec- extended left hemihepatectomy. In the pure lapa-
tomy is the same as that of the open proce- roscopic procedure, the entire resection of the
dure. With proper patient selection and liver is completed through laparoscopic ports;
laparoscopy surgical technique, the left hemi- hand-assist devices or working incisions are not
hepatectomy can be performed safely. used, although a small incision may be made for
specimen extraction. Hand-assisted laparoscopy
Keywords is defined by the elective placement of a hand
port for facilitating the procedure. And, the
Laparoscopic liver resection · Laparoscopic hybrid technique is defined as a procedure, which
left hemihepatectomy · Pure laparoscopy is started as a pure laparoscopic, or a hand-­
Surgical procedure · Surgical technique assisted procedure but the resection is performed
through a mini-laparotomy incision [1]. The con-
tents to be described below are pure laparoscopy-­
oriented explanations.

13.2 Indications
Supplementary Information The online version con-
tains supplementary material available at https://doi. Laparoscopic left hemihepatectomy is performed
org/10.1007/978-­981-­16-­1996-­0_13. if the liver tumor is in segment IV or left lateral
segments (segment II/III) when it is expected that
K.-H. Kim (*) · H.-D. Cho
Division of Hepatobiliary Surgery and Liver
Transplantation, Department of Surgery, Asan
Medical Center, University of Ulsan College of
Medicine, Seoul, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 71

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_13
72 K.-H. Kim and H.-D. Cho

sufficient resection margin would not be obtained 13.4 Patient Position

as left lateral sectionectomy. However, to per-
form safe laparoscopic surgery, the tumor must The patient lies in the lithotomy position under
not be attached to the liver hilum and major ves- general anesthesia. At this time, the operator
sels such as IVC and middle hepatic vein. It can stands between the two legs of the patient (French
also be performed when symptomatic intrahe- position); the first assistant stands at the upper
patic stones are in the left lobe, and there is steno- left side of the patient and the second assistant
sis of the left biliary tract that causes suspicion of stands with the camera at the lower left side.
malignancy. Occasionally, the operator would stand on the
right side of the patient, but in experience, stand-
ing between the legs of the patient is optimal for
13.3 Preoperative Examination laparoscopic liver resection.

The preoperative examination should be done to

ensure that the liver function is enough for resec- 13.5 Trocars Site
tion and to recognize the patient’s anatomy. The
general blood test is the same as the open proce- Generally, a total of five trocars are used. The
dure. It is recommended to perform a three-­ procedure is feasible with four trocars, but add-
dimensional CT or MRI that reconstructs the ing a 5 mm trocar can provide a much more con-
hepatic arteries, portal vein, and biliary tract of venient resection. The pneumoperitoneum is
the liver. The anatomy of the liver has a lot of made by the open or closed method, and the tro-
variations; it is necessary to recognize the car for the camera is located just above the umbi-
patients’ liver anatomy and make a plan before licus or slightly upper left side. The operator
surgery. In particular, the right posterior hepatic utilizes two trocars. The main working trocar for
duct drains to the left hepatic duct in about 30% hepatectomy is 12 mm in size and is inserted at
of the cases, and determining the left bile duct the point where the right rib meets the mid-­
resection site is very important to prevent dam- clavicular line under visualization of the camera.
age to the right posterior bile duct (Fig. 13.1) [2]. The second trocar measuring the same size is
inserted directly below the rib cage along the
right anterior axillary line. At this trocar site, an
atraumatic grasper is often used to pull the liver,
or an automatic anastomosis device can be
inserted depending on the angle of the left hepatic
vein.
Two trocars are used by the first assistant. A
12 mm trocar is placed directly below the xiphoid
process, whose main functions are suction and
irrigation. The other 5 mm trocar is inserted at the
point where the left rib meets along the left mid-
dle clavicle line. The first assistant uses an atrau-
Fig. 13.1 The right posterior bile duct has an anomalous matic grasper to pull the liver through this trocar
drainage to the left bile duct during resection (Fig. 13.2) [3, 4].
13 Laparoscopic Left Hemihepatectomy 73

Position of the stump and apply a clip underneath. If a

Left-sided laparoscopic resection hole is formed in the main hepatic vein, hemo-
stasis can be done with a bipolar device or with a
suture using prolene 6-0. Under conditions of
nonfeasibility, the hole should be with hemo-
1st assist static agents or gauze and the procedure should
be delayed until the bleeding stops. In most
main working port
cases, this will lead to hemostasis. If you care-
fully dissect around the parenchyma of the
retrieval site bleeding focus while pressing that area, you can
eventually find the exact bleeding focus and stop
bleeding. However, if you fail to control bleed-
2nd assist
ing with these m­ easures, you must boldly switch
to an open conversion. The transition to open
surgery is never a problem and is necessary for
surgeon the patient’s safety.

13.8 Surgical Technique

Fig. 13.2 The patient was placed in the lithotomy posi-
tion in the 30° reverse Trendelenburg position, with the 13.8.1 Round Ligament Division
surgeon standing between the donor’s legs. The 1st assis-
tant and the 2nd assistant were located on the left side of The round ligament is first excised for the mobi-
the patient
lization of the liver. In the case of right hemi-
hepatectomy, the falciform ligament should be
13.6 Pneumoperitoneum adequately left for fixation of the remnant left
liver, but in the case of left hemihepatectomy, it is
In general, abdominal pressure is maintained not necessary.
below 12 mmHg. It has been reported that raising
the abdominal pressure during bleeding may help
stop the bleeding, but raising the abdominal pres- 13.8.2 Cholecystectomy
sure for a long time is considered a high risk for
air embolism; therefore, special care should be In the case of a left hemihepatectomy, cholecys-
taken. tectomy is not performed routinely unless there is
a problem with the gallbladder. When resecting
the liver, it is convenient to perform surgery while
13.7 Bleeding Control holding the gallbladder with an atraumatic
grasper with the surgeon’s left hand and pulling it
Usually, laparoscopic liver resection causes less outwards.
bleeding than conventional open liver resection
due to several reasons. The pneumoperitoneum
itself can lead to less bleeding and a magnified 13.8.3 L
 eft Hilar Dissection and ICG
view by the camera can lead to a more meticu- (Indocyanine Green)
lous surgery. Careful parenchymal resection of Technique
the liver and Pringle maneuver are performed to
minimize bleeding unless there is a contraindica- There are two methods of the left hilar dissection.
tion (15 min of occlusion and 5 min of reperfu- The first is the Glissonean pedicle approach [5]
sion). In the case of bleeding from small vessels and the second is the individual isolation
with a stump, the dissector is used to hold the tip approach. Since biliary malformations can be
74 K.-H. Kim and H.-D. Cho

present in 30% of cases [2], a thorough review of

the preoperative imaging studies is mandatory
and, if necessary, intraoperative cholangiography
should be performed before and after biliary divi-
sion, to ensure that the division has been safely
performed.
In the method of the Glissonean pedicle
approach, after confirming the hepatic hilum, the
liver parenchyma around the left Glissonean ped-
icle is dissected to make space. When the
Glissonean pedicle is clamped with a Bulldog
clamp, the ischemic boundary for resection of the
lobe can be seen.
In the individual isolation method, the first
Fig. 13.4 The left portal vein was tied off
assistant lifts the left lobe for the operator, and
the operator dissects the left hepatic artery using
the dissector, clips the Hem-o-lok® clip twice on 13.8.4 Liver Mobilization
the remnant side, and seals the artery stump of
the specimen side using an energy device For benign diseases, liver mobilization may be
(Fig. 13.3). The left hepatic portal vein may be performed first, but in the case of malignant
divided after isolation, but if there is a risk of tumors, it is recommended to first block the blood
bleeding during the left portal vein isolation due inflow to avoid the chance of tumor spread. After
to the small portal branches around it, it may be removing the left coronary ligament and the left
ligated with a small clip and divided with the left triangular ligament using the energy device, the
hepatic duct with Endo-GIA™ after parenchy- lateral side of the left hepatic vein is exposed. If
mal transection of the liver (Fig. 13.4). the lateral side of the liver is large, it is conve-
Regarding the ICG injection, 2.5 mg of ICG is nient to separate the ligament after placing the
injected intravenously after isolation and clamp- gauze between the spleen, omentum, and liver.
ing of the Glisson of the liver to be resected. When dividing the hepatogastric ligament,
Then, ICG is administrated into the entire rem- there may be blood vessels going to the liver in
nant liver segment, excluding the clamped side the ligament, which can be ligated using a Hem-­
(Video 13.1). o-­lok® clip on the remaining side and divided
using an energy device.

13.8.5 L
 iver Parenchymal
Transection

The surface of the liver is transected using an

energy device along the ischemic boundary, and
the deep part of the liver is transected with an
ultrasonic aspirator equipped with a long tip for
laparoscopy. An ultrasonic aspirator has to move
widely to the left and right and shallow to the top
and bottom to reduce the Glissonean pedicle
injury and for safe parenchymal transection. As
Fig. 13.3 The Left hepatic artery was applied with Hem- in the left hemihepatectomy, full exposure of the
o-lok® clip middle hepatic vein is important during paren-
13 Laparoscopic Left Hemihepatectomy 75

chymal transection for the anatomical resection.

Occasionally, a small branch of the middle vein
may be damaged and bleed, but in most cases, it
is stopped by transient pressing with a gauze-type
hemostatic agent.

13.8.6 Left Hilar Division

The left Glissonean pedicle exposed after paren-

chymal transection is divided using the Endo-­
GIA™. If the bile duct has an anatomical
variation such that the right-side bile duct drains
to the left bile duct, using the Endo-GIA™ in the Fig. 13.6 The left hepatic vein was divided using
distal part to the maximum extent possible to pre- Endo-GIA™
vent biliary damage is preferred (Fig. 13.5).

13.8.9 C
 heck Resection Margin
13.8.7 Left Hepatic Vein Division and Drain Tube Insertion

After the division of the left Glissonean pedicle, Occasionally, there may be bleeding at the resec-
the left hepatic vein is exposed easily when the tion margin when using the Endo-GIA™, so it is
remaining parenchyma is removed and divided better to clip using small clips at the resection
using the Endo-GIA™ (Fig. 13.6). site. After bleeding control, a hemostatic agent
should be applied to the resection margin and the
drain tube should be placed on the resection
13.8.8 Specimen Extraction margin.

The resected left lobe is placed in an Endo-bag

and removed from Pfannenstiel incision, the 13.9 Summary
transverse incision just above the pubic symphy-
sis. The length of the incision is determined Laparoscopic left hemihepatectomy can be per-
according to the volume of the resected liver. formed with surgical indications such as the open
left hemihepatectomy. With the proper patient
selection and surgical technique for laparoscopy,
the left hemihepatectomy can be performed
safely.

References
1. Buell JF, Cherqui D, Geller DA, O'Rourke N, Iannitti
D, Dagher I, et al. The international position on lapa-
roscopic liver surgery: the Louisville statement, 2008.
Ann Surg. 2009;250(5):825–30.
2. Choi JW, Kim TK, Kim KW, Kim AY, Kim PN, Ha
HK, et al. Anatomic variation in intrahepatic bile
ducts: an analysis of intraoperative cholangiograms
in 300 consecutive donors for living donor liver trans-
Fig. 13.5 The left bile duct was divided using plantation. Korean J Radiol. 2003;4(2):85–90.
Endo-GIA™
76 K.-H. Kim and H.-D. Cho

3. Cho HD, Kim KH, Hwang S, Ahn CS, Moon DB, open left hemihepatectomy for left-sided hepatolithia-
Ha TY, et al. Comparison of pure laparoscopic ver- sis. Int J Med Sci. 2014;11(2):127–33.
sus open left hemihepatectomy by multivariate 5. Takasaki K. Glissonean pedicle transection method for
analysis: a retrospective cohort study. Surg Endosc. hepatic resection: a new concept of liver segmentation.
2018;32(2):643–50. J Hepato-Biliary-Pancreat Surg. 1998;5(3):286–91.
4. Namgoong JM, Kim KH, Park GC, Jung DH, Song
GW, Ha TY, et al. Comparison of laparoscopic versus
 Laparoscopic Left Lateral
Sectionectomy 14
In Seok Choi and Ju Ik Moon

Abstract 14.1 Indication

Laparoscopic left lateral sectionectomy can be
applied easily among several laparoscopic • Malignant tumors located on the left side of
hepatic segmental resection procedures. This the falciform ligament (hepatocellular carci-
chapter discusses the technical aspects of lap- noma, metastatic liver cancer, and intrahepatic
aroscopic left lateral sectionectomy, including liver cancer).
instrument and patient position, location of • Benign tumors (cystic adenoma, hemangioma,
trocars, liver traction, and surgical procedures and other cystic tumors).
steps. Also, the authors provide useful tips for • Intrahepatic stones (when intrahepatic stones
laparoscopic left lateral sectionectomy. without stenosis in the main left bile duct are
localized in the left lateral section).
Keywords

Laparoscopy · Left lateral sectionectomy 14.2 The Patient’s Posture

Laparoscopic liver resection · Glisson and the Position
of the Operators

• Operate in a supine state with elevated head

position (Reverse Trendelenburg).
• Depending on the preference of the operator
or the patient’s body mass, you can choose
French posture with both legs spread apart.
• The surgeon is on the right side of the patient,
and the assistant and scopist are on the left
Supplementary Information The online version con- side. Depending on the preference of the oper-
tains supplementary material available at https://doi. ator, the operator can be positioned between
org/10.1007/978-­981-­16-­1996-­0_14.
both legs to perform surgery (Fig. 14.1).

I. S. Choi (*) · J. I. Moon

Department of Surgery, Konyang University Hospital,
Konyang University School of Medicine,
Daejeon, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 77

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_14
78 I. S. Choi and J. I. Moon

1st
assistant

Operator

scopist

Fig. 14.2 Liver mobilization

Fig. 14.1 Position of the operator and trocar parenchyma, approaching the diaphragm, and
exfoliated to the area where the inferior vena
cava and the left hepatic vein meet.
14.3 Locations of Trocars • Dissect the left coronary ligament while pulling
down the left lateral lobe of the liver. At this
• For the first trocar (A), after making an inci- time, to avoid injuring the diaphragm, the liga-
sion of 1 cm in size at the bottom of the umbi- ment is peeled off by contacting the paren-
licus, an 11–12 mm trocar is inserted following chyma, and when the left triangular ligament is
the Hasson method to create pneumoperito- exposed, it is ligated with a clip or hemlock.
neum and then a camera is inserted. • After the left triangular ligament is cut, the left
• In the case of the second trocar (B), a 12 mm lateral segment is lifted to expose the hepato-
trocar is inserted in the right part of the midline gastric ligament. To easily expose the left
into the patient’s right upper abdomen and used hepatic vein, the ligament may be exfoliated,
as the primary (main) port for the operator. and depending on the operator, exfoliation
• In the case of the third trocar (C), a 5 mm trocar may not be performed.
is inserted 2–3 cm below the rib cage of the • Ligamentum teres is used for traction after
clavicle midline in the patient’s right upper cutting according to the taste of many other
abdomen and is used by the operator’s left hand. surgeons. In the case of this author, it is used
• In the case of the fourth trocar (D), a 5 mm trocar for traction without cutting.
is inserted in the patient’s upper left abdomen
5–7 cm below the costal margin of the clavicle
midline and used by the assistant surgeon. 14.4.2 Liver Traction (Fig. 14.3)
• Tip: Depending on the level of the assistant’s
skills or the progress of the surgery, a 5 mm • For laparoscopic liver resection, retraction of
trocar may be added to the upper left abdomen the liver is an essential process, and in the case
if necessary. of the author’s experience, a 2-0 prolene
straight needle is used to insert the straight
needle from the outer side of the right upper
14.4 Steps of Surgery abdomen, tied to the ligamentum teres, and
then pulled out to the needle to the right-side
14.4.1 Mobilization of the Liver traction. Left-side traction is performed by
(Fig. 14.2) stay suture to the parenchyma of the left lat-
eral lobe using a 2-0 prolene straight needle
• Using an ultrasonic energy device, the falci- and a rubber band and then pulled out toward
form ligament is dissected upward close to the the left lateral abdominal wall.
14 Laparoscopic Left Lateral Sectionectomy 79

Fig. 14.4 Glisson’s approach with the endoscopic auto-

matic anastomosis device

Fig. 14.3 Liver traction method

matic endoscopic anastomosis device of
• For the beginners, the right-side traction can appropriate thickness should be used, and
be done by pulling the ligament teres with the multiple cartilages may be used as needed.
left hand of the operator, and the left-side trac- • Tip: Endoscopic automatic anastomosis
tion using the liver retractors (snake retractor device is inserted into the hepatic parenchyma
or fan retractor) can easily expose the cut sur- in the horizontal direction with the falciform
face of the liver. ligament to the maximum extent possible.
• Tip: Individual Glisson method for 2 and 3
segments: Along the left side of the umbilical
14.4.3 Liver Resection by Glissonean portion, the soft tissue around the area sus-
Approach pected to be the Glisson area in segment 3 is
removed, and the Glisson branch and the
• By traction of the left and right lobes of the hepatic parenchyma are carefully dissected
liver toward the left and right sides, the paren- with a suction tip. With the suction tip and
chyma on the left side of the falciform liga- right-angle device, the upper and lower parts
ment gets well exposed. First, the cutting line of the branch are continuously peeled off,
is marked on the left side of the falciform liga- and when the upper and lower parts of the
ment using an electric cauterizer, and the branch are penetrated, the proximal and dis-
parenchyma is cut 1–2 cm from the liver sur- tal parts of the detached segment 3 Glisson
face using an ultrasonic energy device or a branch are ligated and cut with a hemolock.
vessel sealing device. For deeper parenchymal After cutting the Glisson branch in segment
dissection or blood vessel exposure, CUSA is 3, if the hepatic parenchyma is slightly dis-
used to dissect the hepatic parenchyma. sected, the Glisson branch in segment 2 is
• Dissect the parenchyma to expose the exposed and cut in the same way.
Glisson branches. After that, secure enough Subsequently, the hepatic parenchyma is
space for the endoscopic anastomosis. peeled to expose the hepatic vein.
Glisson branch is processed in batch using • Tip: Liver resection by an individual approach
an endoscope automatic anastomosis is practically not used much recently because
machine measuring 60 mm in size (Blue, the umbilical portion has a difficult anatomi-
Gold cartilage) (Fig. 14.4). cal structure, and it is difficult to individually
• Tip: Depending on the preference of the oper- cut and treat the hepatic portal vein and hepatic
ator or the thickness of the Glisson, an auto- artery.
80 I. S. Choi and J. I. Moon

After the Glisson branch is cut using the

endoscopic automatic anastomosis device, the
remaining hepatic parenchyma is separated
using ultrasonic energy devices, vessel sealing
devices, or CUSA to expose the left hepatic
vein, and the hepatic vein is cut using the
endoscopic automatic anastomosis device
measuring 60 mm in size (white cartilage)
(Fig. 14.5).
• Tip: In patients with intrahepatic duct stones,
residual stones need to be checked if the
Glisson branches draining to the left lateral
segment are thickened by inflammation and it
Fig. 14.5 Ligation of left hepatic vein
is difficult to separate the Glisson branches or
if the intrahepatic duct stone is in the intrahe-
patic duct proximal to the umbilicus. The
intrahepatic bile duct on the resected surface
should be exposed. First, the liver portal vein
and the hepatic artery are individually sepa-
rated, and then the lateral bile ducts are par-
tially exposed after cutting the vessels. After
exposing as much of the bile duct as possible
to the upper parenchyma of the bile duct using
CUSA and the ultrasonic energy device, cut
the bile duct using the device. After removing
intrahepatic stones through an open bile duct,
Fig. 14.6 Hepatic specimen removal using an umbilical
the bile duct is sutured and closed.
port

14.4.4 Drain Insertion and Extraction • The excised left lateral section is placed in an
of the Surgical Specimen endoscopic plastic bag and removed through
an incision extending toward the 12 mm trocar
• After applying fibrin glue to the liver resection region of the umbilicus or the Pfannenstiel
surfaces, place the drainage tube around it. incision (Fig. 14.6).
 Laparoscopic Right
Hemihepatectomy 15
Ho-Seong Han and Jai Young Cho

Abstract manuscript describes details of standard sur-

gical techniques, instruments, and precau-
As the potential applications for LLR have
tions in a stepwise manner.
expanded considerably, laparoscopic left lat-
eral sectionectomy is now regarded as a stan-
Keywords
dard treatment option (Guro H, Cho JY, Han
HS, Yoon YS, Choi Y, Periyasamy M. Clin Laparoscopy · Right · Major · Donor
Mol Hepatol. 22:212–218, 2016). However,
laparoscopic major liver resection including
laparoscopic right hepatectomy is still con- 15.1 Indication
sidered a difficult operation. Recently, laparo-
scopic right hemihepatectomy has been 1. Hepatocellular carcinoma occupying the right
increasingly performed in patients with hepa- hemiliver, metastatic tumor with no evidence
tocellular carcinoma or metastatic liver of extrahepatic disease, and intrahepatic chol-
tumors by the accumulation of experiences angiocarcinoma confined to the right lobe of
and development of instruments (Guro H, the liver.
Cho JY, Han HS, Yoon YS, Choi Y, Kim S, 2. Benign liver tumors with the presence of
Kim K, Hyun IG. Surg Oncol. 27:31–35, symptoms, the danger of rupture, and uncer-
2018; Han HS, Yoon YS, Cho JY, Ahn tainty of diagnosis.
KS. Ann Surg Oncol. 17:2090–2091, 2010). 3. Hepatolithiasis associated with duct stricture,
Successful laparoscopic donor right hepatec- atrophy of the diseased liver parenchyma, or
tomy has also been reported (Han HS, Cho both.
JY, Yoon YS, Hwang DW, Kim YK, Shin HK, 4. The living donor with favorable anatomy for
Lee W, Surg Endosc. 29:184, 2015). This adult-to-adult living donor liver transplanta-
tion.
Supplementary Information The online version con-
tains supplementary material available at https://doi.
org/10.1007/978-­981-­16-­1996-­0_15.

H.-S. Han (*) · J. Y. Cho

Department of Surgery, Seoul National University
Bundang Hospital, Bundang-gu, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 81

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_15
82 H.-S. Han and J. Y. Cho

15.2 Patient Position and Trocar 15.3 Operative Technique

Placement
1. After insertion of the first trocar, pneumoperi-
1. The patient is always placed in a supine posi- toneum is established and maintained at
tion with split legs. The table is usually kept in 10–12 mmHg. A flexible laparoscope is used.
reverse Trendelenburg’s position with the After exploration of the peritoneal cavity for
right side up. signs of unresectable disease, intraoperative
2. Five trocars are usually used (Fig. 15.1). The ultrasound is performed to define the location
diameter of the trocar depends on the instru- and extent of the lesion.
ment used, so 12 mm trocar for the scope, 2. Complete mobilization of the right lobe of the
CUSA, stapler, fan retractor, and the rest is liver by dissection of triangular and coronary
5 mm. The 12 mm trocar placement for the ligaments and diaphragmatic attachments is per-
main working port (Port C in Fig. 15.1) is formed. Separation of the falciform ligament
adjusted according to the size of the patient’s from the anterior abdominal wall is done using
body and abdominal cavity and location of the ultrasonic shears till full exposure of inferior
tumor. vena cava is achieved. A few short hepatic veins
3. The operator usually stands between the are ligated using clips (Fig. 15.2).
patient’s legs. Occasionally, the operator 3. Inflow control can be done by the Glisson
moves to the right side of the patient during approach or by individual ligation. When the
the operation. Glissonean approach is adopted for right-­

C
E
Assistant
B A

Scopist

Operator

Fig. 15.1 Trocar placement and position of the surgeons

15 Laparoscopic Right Hemihepatectomy 83

Fig. 15.3 Isolation of right Glisson pedicle

Fig. 15.2 Dissection of the inferior vena cava

sided resection, hilar dissection is performed

to isolate the right Glisson’s pedicles at the
inferior surface of the quadrate lobe. To iso-
late and tape the right pedicle, a long right-­
angle type clamp or curved dissector is
considered as valuable. After taping the right
pedicle, the whole pedicle can be ligated en
masse by an Endo stapler (Fig. 15.3).
4. For living donors or patients with hepatolithia-
sis, individual ligation is preferred (Fig. 15.4).
After right hepatic artery isolation with metic-
ulous dissection, the right portal vein could be
isolated with blunt atraumatic forceps. The
demarcation line is made after temporary
clamping of the artery and portal vein.
5. For parenchymal dissection for superficial
Fig. 15.4 The right hepatic artery and portal vein are iso-
liver tissue, ultrasonic shear is very useful and lated and taped
considered a fast energy device (Fig. 15.5). If
the donor has significantly large V5 and/or V8
branch, those should be widely and safely dis- 6. The final step is ligation of the right hepatic
sected for future reconstruction. Then CUSA vein at the origin of the vein root using a
is used to dissect the deep part of parenchyma stapler (Fig. 15.7). After retrieval of graft
with bipolar diathermy. The hanging maneu- or right liver through the suprapubic inci-
ver is beneficial to facilitate parenchymal dis- sion, hemostasis and drain insertion are
section (Fig. 15.6). done.
84 H.-S. Han and J. Y. Cho

Fig. 15.5 Superficial parenchymal dissection using Fig. 15.7 The right hepatic vein is ligated using a
ultrasonic shears stapler

Further Reading
Guro H, Cho JY, Han HS, Yoon YS, Choi Y, Periyasamy
M. Current status of laparoscopic liver resection
for hepatocellular carcinoma. Clin Mol Hepatol.
2016;22:212–8.
Guro H, Cho JY, Han HS, Yoon YS, Choi Y, Kim S, Kim
K, Hyun IG. Outcomes of major laparoscopic liver
resection for hepatocellular carcinoma. Surg Oncol.
2018;27:31–5.
Han HS, Yoon YS, Cho JY, Ahn KS. Laparoscopic right
hemihepatectomy for hepatocellular carcinoma. Ann
Surg Oncol. 2010;17:2090–1.
Han HS, Cho JY, Yoon YS, Hwang DW, Kim YK, Shin
HK, Lee W. Total laparoscopic living donor right hep-
atectomy. Surg Endosc. 2015;29:184.

Fig. 15.6 Hanging maneuver during laparoscopic right

hepatectomy
 Part II
Deceased Donor Liver Transplantation
 Liver Procurement in a Deceased
Donor 16
Hee Chul Yu and Jae Do Yang

Abstract 16.1 Procedures

The goal of donor management and selection is
A skin incision is made via the xiphoid process to
maximizing the number of organs procured and
the point just above the symphysis pubis and is
transplanted for each deceased donor while
transversely extended up both flanks at the level
maintaining optimal function of those organs
of the umbilicus (Fig. 16.1a, b).
[1]. The concept of multiple abdominal organ
If thoracotomy is needed for the donor, the
procurement techniques was outlined by Starzl
incision line is extended toward the suprasternal
[2–4].
notch, followed by opening the chest using a ster-
For the deceased donors, wide exposure to
nal saw and a Finochietto sternal retractor
the abdominal and thoracic organs is required,
(Fig. 16.1c).
as well as access to the aorta and the provision
In order to provide sufficient exposure of the
of sufficient venous venting [5–8]. The basic
liver, the round and the falciform ligament of the
concepts of liver procurement include less
liver is divided and tied (Fig. 16.2a, b).
warm dissection, good perfusion, and rapid
Examination of the intra-abdominal organs is
cooling [9].
carried out to exclude the presence of potential
These concepts must be integrated into
malignant disease. The quality of the liver is usu-
simple and systematic procedures in order to
ally assessed at this stage, and a liver biopsy is
promote a stable operation [10, 11].
recommended to evaluate the percentage of mic-
rosteatosis. Next, the left lateral section of the
Keywords
liver is separated from its ligamentous attach-
Deceased donor · Liver procurement · Warm ments by the division of the left coronary and tri-
dissection · Perfusion angular ligaments (Fig. 16.2a, c).
Careful exposure of the hepatogastric liga-
ment must be performed. Inspection and palpa-
Supplementary Information The online version con- tion of the arterial supply of the liver can be
tains supplementary material available at https://doi. performed at this time by paying close attention
org/10.1007/978-­981-­16-­1996-­0_16.
to anatomical variants, such as accessory or
replace the right hepatic artery from the superior
H. C. Yu (*) · J. D. Yang mesenteric artery (SMA) and accessory or
Department of Surgery, Jeonbuk National University replace the left hepatic artery from the left gastric
Medical School, Jeonju, South Korea artery (Fig. 16.3a, b).
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 87

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
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88 H. C. Yu and J. D. Yang

a b

Fig. 16.1 (a) A skin incision. (b) A schematic view of midline and vertical incisions. (c) The towel clip fixed to the
abdominal wall, and the chest is opened using the Finochietto retractor

Diaphragm
a b
Right triangular
ligament

Left triangular
ligament

Falciform
ligament

Round
ligament

Hepatic ligaments suspending the liver to the diaphragm

and anterior abdominal wall.

Fig. 16.2 (a) The peri hepatic ligaments. (b) Resection of the round and falciform ligament. (c) Left coronary (black
arrow) and triangular ligament (white arrow)
16 Liver Procurement in a Deceased Donor 89

a b

Fig. 16.3 Identification of anatomical variations of the hepatic artery. (a) Inspection of the gastrohepatic ligament for
the left hepatic artery. (b) Inspection of the foramen of Winslow for the right hepatic artery

a b

Fig. 16.4 Mobilization of the intestinal and retroperitoneal vessels. (a) Dissection of the ascending colon along the
white line of Toldt. (b) Division of the Lt RV, SMA, and IMA after Kocherization

Preparation of aortic cannulation. The right iliac artery bifurcation using umbilical tape
colon and the terminal small intestine are moved (Fig. 16.5).
cephalad and retracted to the left side (Fig. 16.4a) At this time, careful dissection is needed to
The Kocher maneuver is performed to mobilize avoid damaging the vertebral artery that posteri-
the duodenum. Peritoneal reflections between the orly branches out from the aorta.
duodenum and retroperitoneal areas are dissected The abdominal or thoracic aorta is used to
and incised, thereby exposing entire retroperito- cross-clamp based on the circumstances.
neal structures like the aorta, inferior vena cava If the chest is not opened, the cross-clamp at
(IVC), renal vein (RV), SMA, inferior mesenteric the abdomen is applied over the supraceliac aorta.
artery (IMA), and the inferior mesenteric vein Umbilical tape is used to encircle the aorta
(IMV) (Fig. 16.4b). after dissection of the diaphragmatic crus in addi-
IMV (or SMV in case of without pancreas tion to a retracted left lateral section to the right
procurement) is looped with a 3–0 black silk side and esophagus to the left side (Fig. 16.6a, b).
for portal cannulation. Arterial perfusion is If the chest is opened, the intrathoracic
usually performed by cannulating at the infra- descending aorta is cross-clamped by opening
renal aorta. The aorta is encircled above the the left side of the chest (Fig. 16.6c).
90 H. C. Yu and J. D. Yang

Histidine-Tryptophan-Ketoglutarate (HTK) arin should be given intravenously. The gall-

solution and a cannula (aorta 18–22 fr, portal bladder is incised and irrigated using saline to
10-12Fr) are connected, and crushed ice is pre- reduce autolysis of the bile duct membrane
pared. At least 3 minutes before infusion of the (Fig. 16.7).
preserving solution, a dose of 300 U/kg of hep- The abdominal aorta is ligated distally using
the umbilical tape above the bifurcation of the
iliac artery and is proximally incised up to about
one-third toward the interior while holding using
the thumb and index finger.
After lumen examination, place the tube so
that its end is located below the renal artery and
ligated (Fig. 16.8a, b). The IMA or SMV is can-
nulated at the portal perfusion (Fig. 16.8b).
Immediately before the infusion of the pre-
serving solution, the aorta (abdominal or tho-
Fig. 16.5 Exposure of the IMV for portal cannulation
racic) should be clamped and must be infused
(3-0 black silk tapping) and infrarenal aorta for aortic can- with cold preserving solution under 150 mmHg
nulation (umbilical tapping) pressure measured using a pneumatic cuff. The

a b

Fig. 16.6 (a) Dissection of the diaphragmatic crus (white arrow). (b) Exposure of the abdominal aorta. (c) Dissection
of the descending (thoracic) aorta
16 Liver Procurement in a Deceased Donor 91

suprahepatic IVC (or caval-atrial junction, infra- divided into the gastroesophageal junction along
renal IVC) should be transected to allow exsan- the lesser curvature of the stomach (Fig. 16.10c).
guinations of the abdominal organ (Fig. 16.9a–d). The duodenum and antrum of the stomach are
Five liters of HTK solution should be run through retracted inferiorly (Fig. 16.11a). CBD resects
the aortic perfusion. The aortic (30–60 ml/kg) the duodenal upper border without causing any
and IMV/SMV (1–2 L) cannulae are flushed in vascular injury (Fig. 16.11b). GDA is dissected at
both the perfusions. The liver, kidney, and pan- the left part of the CBD (Fig. 16.11c).
creas are completely covered with ice to facilitate PV is identified by dividing the fibrous tissue
rapid cooling of the abdominal viscera. at the superior margin of the pancreas. If the pan-
Liver procurement involves the common bile creas is not procured, the head of the pancreas is
duct, gastroduodenal artery (GDA), portal vein divided (Fig. 16.12a). SMV/splenic vein (SV)
(PV), splenic artery (SA), SMA, infrahepatic (distal part) is identified, cut, and moved proxi-
IVC, and perihepatic ligaments. After perfusion, mally along with the PV (Fig. 16.12b).
the caval-atrial junction at the venting site is The common hepatic artery (CHA) is identi-
completely divided (Fig. 16.10a). In the case of a fied and cut after dissection of the CA up to the
thoracic cross-clamp, the lower part of the clamp- SA along the superior margin of the pancreas
ing site is divided and dissected to the abdominal (Fig. 16.13a, b). If the pancreas is procured, PV
aorta (Fig. 16.10b). The gastrohepatic ligament is and SA should be divided from the superior bor-
der and the proximal part of the pancreas in order
to avoid vessel injury.
At the inferior part of the pancreas, the origin
of the SMA at the aorta is dissected. If the pan-
creas is not procured, a midline incision (2–3 cm)
at this point is performed, while preventing injury
to the accessory or aberrant hepatic arteries. After
the SMA is divided and the right renal artery or
accessory vessel is identified, the aorta is cut and
mobilized (Fig. 16.14a, b).
To identify both the renal veins in the lumen, a
partial incision of the infrahepatic IVC is per-
formed at the superior part of the left renal vein
(Fig. 16.15a). After cutting the IVC (Fig. 16.15b),
Fig. 16.7 The gallbladder is incised and irrigated using the hepatorenal ligament is carefully divided,
saline fluid

a b

Fig. 16.8 (a) Cannulation and ligation of the distal aorta. (b) Cannulation of the distal aorta and IMV for perfusion
92 H. C. Yu and J. D. Yang

a b

Partial cut Thoracic aorta cross clamp

for drainage

IMA Portal cannulation

Aorta cannulation

c d

Fig. 16.9 (a) Perfusion of HTK solution after clamping cooling of visceral organs using ice. (d) Preserving solu-
of the thoracic aorta. (b) Suprahepatic IVC and partial tion infused under 150 mmHg of pressure using a pneu-
incision of the caval-atrial junction for venting. (c) Rapid matic cuff

while the right kidney is retracted inferiorly to divided (Fig. 16.16a). After identification of the
protect from injury (Fig. 16.15c). CBD, GDA, and SA, the liver, along with the
A finger is inserted into the lumen of the aorta, SMA, and CA is divided (Fig. 16.16b).
suprahepatic IVC in order to avoid injury, the Finally, the liver is procured.
areas of the diaphragm surrounding the liver are
16 Liver Procurement in a Deceased Donor 93

a b

Fig. 16.10 (a) Division of the suprahepatic IVC-atrial junction. (b) Abdominal aorta dissection after cutting of the
thoracic aorta. (c) Gastrohepatic ligament dissection at the gastroesophageal junction

a b c

D CBD.
GDA
P

D
CBD.
GDA

Fig. 16.11 (a) Schematic view after inferior traction of the first portion of the duodenum. (b) Dissection of the CBD
on the superior margin of the duodenum. (c) GDA dissection on the left side of the CBD
94 H. C. Yu and J. D. Yang

a b

Fig. 16.12 (a) Exposure of PV/SV and SMV after incision of the pancreatic head. (b) Division of PV after dissection
of the SMV and SV

a b

Fig. 16.13 (a) Schematic view of resection parts including the CBD, PV, and the common hepatic artery (CHA). (b)
SA is resected after dissection along the superior border of the pancreas
16 Liver Procurement in a Deceased Donor 95

a b

Fig. 16.14 (a) SMA resection at the abdominal aorta. (b) Identification of the right renal artery and accessory renal
vessels after partial incision of the SMA

a b

Fig. 16.15 (a) Partial incision of the infrahepatic IVC above the left renal vein. (b) Complete resection of the infrahe-
patic IVC. (c) Resection of the hepatorenal ligament for the division of the liver (lower part)
96 H. C. Yu and J. D. Yang

a b

Fig. 16.16 (a) Insertion of a finger into the lumen of the the inferior part of the liver after hand traction of perihilar
suprahepatic IVC to prevent injury and aid in the dissec- structures for protection
tion of the diaphragm around the liver. (b) Dissection of

Improved early liver function. Transplantation.

References 1996;61:1605–9.
6. Marroquim CE, Kuo PC. Adult cadaveric liver
1. Abu-Elmagd K, Fung J, Bueno J, Martin D, transplan­ tation. In: Kuo PC, Davis RD, edi-
Madariaga JR, Mazariegos G, Bond G, Molmenti tors. Comprehensive atlas of transplantation.
E, Corry RJ, Starzl TE, Reyes J. Logistics and Philadelphia: Lippincott W & W; 2005. p. 99–114.
technique for pro­curement of intestinal, pancreatic, 7. Renz JR, Yersiz H. The donor operation. In: Busttil
and hepatic grafts from the same donor. Ann Surg. RW, Klintmalm GM, editors. Transplantation of
2000;232:680–7. liver. Philadelphia: WB Saunders; (2005):545–559.
2. Casavilla A, Selby R, Abu-Elmagd K, Tzakis A, 8. Sturdevant ML, Humar A. Multiorgan procurement
Todo S, Reyes J, Fung J, Starzl TE. Logistics and from the deceased donor. In: Humar A, Matas AJ,
technique for combined hepatic-intestinal retrieval. Payne WD, editors. Atlas of organ transplantation.
Ann Surg. 1992;216:605–9. London: Springer-Verlag; (2006):1–14.
3. Starzl TE, Hakala TR, Shaw BW Jr, Hardesty RL, 9. Yu HC, Cho BH. How to do I make an organ procure­
Rosenthal TJ, Griffith BP, Iwatsuki S, Bahnson ment in deceased donor? Korean Soc Transplant.
HT. A flexible procedure form multiple cadav- 2006;20:14–24.
eric organ pro­ curement. Surg Gynecol Obstet. 10. Van Buren CT, Barakat O. Organ donation and
1984;158:223–30. retrieval. Surg Clin North Am. 1994;74:1055–81.
4. Starzl TE, Miller C, Broznick B, Makowka L. An 11. Vikraman D, Marroquim CE. Surgical techniques:
improved technique for multiple organ harvesting. Liver procurement and transplantation. In: Blazer
Surg Gynecol Obstet. 1987;165:343–8. III DG, Kuo PC, Pappas T, Clary BM, editors.
5. Imagawa DK, Olthoff KM, Yersiz H, Shackleton Contemporary surgical Management of Liver, bili-
CR, Colquhoun SD, Shaked A, Busuttil RW. Rapid ary tract, and pan­creatic disease. Danvers: World
en bloc technique for pancreas-liver procurement. Scientific Publishing Co. Pte. Ltd.; (2014):237–244.
 Recipient Hepatectomy Without
Venovenous Bypass 17
Jin Sub Choi

Abstract including retro hepatic IVC (inferior vena cava).

The ends of supra and infra hepatic IVC are anas-
The recipient hepatectomy with preservation
tomosed with the upper and lower ends of graft
of the vena cava blood flow is technically dif-
IVC as end-to-end type (Fig. 17.1). However, the
ficult than traditional recipient hepatectomy
anastomosis of IVC is very difficult, or some-
including vena cava. However, this procedure
times anastomotic stenosis may result in a patient
provides an advantage of hemodynamic sta-
with a deep surgical field or large liver graft. The
bility and no venous bypass-related complica-
massive bleeding or air embolism may occur if
tions to the recipient.
the supra hepatic IVC slips out of the vascular
clamp.
Keywords
Recipient hepatectomy with vena cava preser-
Recipient hepatectomy · Vena cava vation has been proposed as an alternate proce-
Preservation · Venous bypass dure for the traditional liver transplantation. This
procedure is sometimes technically difficult than
traditional recipient hepatectomy and offers
The traditional recipient hepatectomy for advantages of maintaining the caval blood flow
deceased liver donor liver transplantation during the anhepatic stage and avoidance of com-
involves removal of the entire diseased liver plications of the veno-venous bypass (Fig. 17.2).

Supplementary Information The online version con-

tains supplementary material available at https://doi.
org/10.1007/978-­981-­16-­1996-­0_17.

J. S. Choi (*)
Division of Hepatopancreaticobiliary Surgery,
Department of Surgery, Yonsei University College of
Medicine, Seoul, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 97

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_17
98 J. S. Choi

Fig. 17.1 Recipient hepatectomy with venous bypass and traditional liver transplantation
17 Recipient Hepatectomy Without Venovenous Bypass 99

Fig. 17.2 Recipient vena cava preserving hepatectomy and piggyback anastomosis

17.1 Liver Mobilization The hilar dissection begins by the incision of

the anterior peritoneum of the hepatoduodenal
The bilateral subcostal incision with vertical ligament along the hepatic margin. Branches of
midline extension is the most commonly used the hepatic artery are ligated and divided. The
abdominal incision for the adult liver transplanta- right gastric or pyloric artery is ligated and
tion that is extended from the right mid axillary divided during the proper hepatic artery dissec-
line to the left mid clavicular line. This wide inci- tion. The gastroduodenal artery is dissected about
sion exposes an entire liver and guarantees easy 1–1.5 cm distal area to use as a Carrell patch of
access to the subdiaphragmatic area, retroperito- artery anastomosis. The common hepatic artery
neum, and IVC. is dissected to a 2 cm proximal area from the
The umbilical ligament containing the dilated bifurcation of the gastroduodenal artery. The
umbilical vein must be ligated and divided. The perivascular adventitia tissue of the artery must
falciform ligament is dissected upwards and the be preserved. The common bile duct is dissected
supra hepatic IVC is exposed within the loose with arterial dissection. The main portal vein
connective tissue. There are some collateral veins trunk is freed from surrounding lymphatic soft
in the falciform ligament that can be easily con- tissue and dissection proceeds distal as far as to
trolled by electrocautery. the right and left portal veins.
100 J. S. Choi

Fig. 17.3 IVC dissection on the right side

After all the components of the hepatoduode-

nal ligament are skeletonized, the right triangular
ligament is divided to initiate liver mobilization.
The liver is raised to the anterior and left side.
The right posterior and inferior aspect of the liver
is detached carefully from the diaphragm, renal
capsule, and adrenal gland. After dividing the
dorsal ligament of IVC, the lateral wall of IVC
and the right adrenal vein are exposed. The right
adrenal vein may be ligated and divided or pre-
served. The anterior aspect of retro hepatic IVC
is gradually detached from the liver by progres-
sive division and ligation of several accessories
or short hepatic veins along the caudocranial
direction as far as the main hepatic veins. The left
edge of the caudate lobe and IVC ligament are
Fig. 17.4 IVC dissection on left side
separated from IVC to free the right hepatic vein
(Fig. 17.3).
The left side dissection begins by the division After the anterior aspect of IVC is freed, the
of the left coronary ligament and the left triangu- liver is hanged between the hepatoduodenal liga-
lar ligament. The lesser omentum is divided after ment and the trunk of three major hepatic veins.
raising the left liver. The accessory or aberrant
left hepatic artery in the lesser omentum is ligated
and divided. The peritoneum attached to the cau- 17.2 Liver Removal
date lobe is divided. The left side of the caudate
lobe is raised to expose the IVC and some short Before clamping the trunk of the right hepatic
hepatic veins are ligated. The common or vein, the right portal vein is ligated to prevent
­individual trunk of the middle and left hepatic hepatic congestion. The trunk of the right hepatic
vein is (are) isolated and encircled (Fig. 17.4). vein is clamped with an angled vascular clamp on
17 Recipient Hepatectomy Without Venovenous Bypass 101

IVC can be made and this temporary porto-caval

shunt can be closed just before portal venous
anastomosis.

17.3 Anastomosis

The graft is placed in the operating field at a proper

position and covered with cold saline-­soaked sur-
gical tapes to keep the graft in cold condition. The
upper caval anastomosis of graft is carried out first
with monofilament 3-0 stitches with the evagi-
nated method. The liver graft should be flushed
during the caval anastomosis and the lower stump
Fig. 17.5 Cava preserving recipient hepatectomy of graft IVC is closed with a vascular stapler or
monofilament 3-0 stitch. The liver graft is revascu-
the caval side, sutured on the liver side, and larized after the portal venous anastomosis. The
divided. The caval stump of the right hepatic vein hepatic artery and the bile duct are reconstructed
is closed with monofilament 5-0 suture. The por- following a traditional transplantation method.
tal trunk is clamped with a curved vascular clamp. With a severe size mismatch between the
The common trunk of the middle and left hepatic recipient hepatic vein and the graft IVC, the pig-
vein is clamped with an angled vascular clamp gyback caval anastomosis is often not easy and
laterally from the left side and the liver is results in severe anastomosis stenosis. The alter-
removed. The septum of the hepatic vein is native to piggyback anastomosis is the side-to-­
divided to make a wide common orifice of the side anastomosis between the recipient IVC and
hepatic vein. Sometimes the incision can be the graft IVC which is made along the longitudi-
extended to the anterior wall of IVC to make a nal axis of IVC. The upper and lower stumps of
wide opening for hepatic vein anastomosis after the graft vena cava should be closed during the
lateral IVC clamping (Fig. 17.5). graft flushing and the side-to-side IVC anastomo-
To prevent the splanchnic congestion during sis should be completed. After the portal vein is
the anhepatic stage, the end-to-side porto-caval anastomosed and graft revascularization, hepatic
shunt between the right portal vein stump and artery, and biliary anastomoses are followed.
 Recipient Hepatectomy
with Venovenous Bypass 18
Gi-Won Song

Abstract 18.1 Mobilization

To avoid unnecessary intraoperative bleeding, of the Recipient’s Liver
total hepatectomy must be carried out along
the precise surgical plane under good visual- 18.1.1 Patient Position and Incision
ization. Although postoperative bleeding can
occur at any site of dissection around the liver, The patient is placed in the supine position with
special attention should be paid to the right the right arm abducted at 90° and the left arm
adrenal gland, subphrenic area, and hepatic close to the body.
hilum for secure hemostasis. To acquire Expose left inguinal region with left thigh
healthy vascular inflows with sufficient length, placed abducted and externally rotated and posi-
we must perform the fine dissection around tioned with a prop under the left knee. Inverted T
the hepatic artery, portal vein, and bile duct incision is made with meticulous bleeding con-
with sufficient information about the vascular trol and ligation of collaterals on the abdominal
anatomy of the hepatic hilum. In the case of wall. To provide excellent exposure to the opera-
total occlusion of inferior vena cava during the tion field, xyphoid process is resected followed
implantation, the veno-venous bypass can by fastidious hemostasis. In patients with a large
provide hemodynamic stability and decom- number of ascites which were not drained preop-
pression of mesenteric blood pressure. But, eratively, ascites should be drained through a slit
the risk of complications such as venous on incision before full laparotomy to prevent
thrombosis, air embolism, lymphocele, etc. contamination and mess of the operation field.
should be considered. Round ligament (ligamentum teres) is ligated and
divided from the abdominal wall during laparot-
Keywords omy, followed by division of falciform ligament
to dissect anterior surface of the liver from the
Deceased donor liver transplantation · Total abdominal wall. Retractors are set up for full
hepatectomy · Veno-venous bypass exposure of the right upper quadrant and its
contents.

G.-W. Song (*)

Division of Hepatobiliary Surgery and Liver
Transplantation, Department of Surgery, Asan
Medical Center, University of Ulsan College of
Medicine, Seoul, South Korea

© Springer Nature Singapore Pte Ltd. 2023 103

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_18
104 G.-W. Song

18.1.2 Division and Mobilization 18.1.3 Division of the Hepatic Hilum

of the Recipient’s Liver
After both sides of the liver are fully mobilized,
Falciform ligament and coronary ligaments are division around the hepatic hilum is followed.
divided with electrocautery cephalad to expose First of all, cholecystectomy is started with cau-
three major hepatic veins entering the IVC. Then, tious attention in dividing around the cystic duct
the right coronary ligament and triangular liga- and cystic artery for collaterals around the gall-
ment are divided to mobilize the right liver lobe bladder. Occasionally, the cystic artery and cys-
from the diaphragm, followed by traction of the tic duct are ligated and divided with the
right liver ventrally to mobilize the right liver gallbladder still attached to the liver to avoid
lobe from the retroperitoneum. While traction of profuse bleeding from the gallbladder fossa.
the right liver to the left side, right adrenal is met After cholecystectomy, dissection of the hepatic
during dissection toward IVC, which should be hilum is started from the left side and proceeded
divided carefully with ligation when it is adher- to the right side. The left side of the hepatoduo-
ent to the liver. The adrenal gland is one of the denal ligament is dissected first to expose the left
most common sites of postoperative bleeding, so hepatic artery and a vessel loop is applied.
careful hemostasis is necessary after the division Different from LDLT, hepatic artery anastomo-
of the adrenal from the liver. After the division of sis in DDLT is mostly performed at bifurcation
the right adrenal is completed, IVC is exposed level of right and left hepatic artery or bifurca-
and mobilized further from the retroperitoneum tion level of proper hepatic artery and gastroduo-
to pass through the left space on the posterior denal artery, so it is not necessary to take hepatic
side of IVC. Different from LDLT, IVC is arteries at a distal location for its maximal length
removed during the recipient hepatectomy in as in LDLT.
DDLT with cavo-caval end-to-end anastomosis. After the left hepatic artery is identified, dis-
The short hepatic veins posterior to the caudate section is proceeded to the right side (of the
lobe are recommended to be resected in order to hepatoduodenal ligament) to expose the left
provide additional exposure to IVC with the portal vein and a vessel loop is applied to it.
secure length for anastomosis. Following the The right side of the hepatoduodenal ligament
division of short hepatic veins with sufficient is dissected to identify the right hepatic artery
length of IVC for cavo-caval anastomosis, a ves- and a vessel loop is applied to it. Right and
sel loop is applied to the infrahepatic IVC. After main portal veins located posterior to right
dissection of the right side is completed, the left hepatic artery are dissected and identified with
coronary ligament and triangular ligament are vessel loops. Thereafter, the common hepatic
divided and the left liver lobe is mobilized from duct is divided at its hilar end followed by
the diaphragm. Several collaterals also exist in meticulous hemostasis around the bile duct. As
this area so vigilance is needed during dissection. the common hepatic duct is divided, the right
During division on the triangular ligament, liga- hepatic artery is identified on its course posteri-
tion before each division is necessary to prevent orly. The right, left, and proper hepatic arteries
bleeding. During traction of the left liver to the are dissected proximally to the bifurcation level
right side, the gastrohepatic ligament is divided of the gastroduodenal artery from the common
up to the hepatic vein. Thereafter, dissection hepatic artery.
around the left side of IVC from retroperitoneum
is performed so that IVC is fully mobilized and
freed on the posterior side.
18 Recipient Hepatectomy with Venovenous Bypass 105

18.2 Installation of Veno-Venous

Bypass

18.2.1 Installation Method

After mobilization of the liver and dissection

around the hilum are completed and prepared for
hepatectomy, the veno-venous bypass is set up for
extracorporeal circulation during the anhepatic
phase (from hepatectomy to implantation of graft
liver). Initially, the pulse of the left femoral artery
is identified on the left inguinal area and vertical Fig. 18.3 Apply vascular tourniquet around the femoral
skin incision around 3 cm is made medially to the vein proximal to the saphenofemoral junction
left femoral artery and perpendicularly to the
inguinal ligament (Fig. 18.1). The subcutaneous section in the cranial direction, which should be
fatty layer (camper’s fascia) is dissected to iden- all ligated and divided carefully. Meticulous liga-
tify a great saphenous vein. The vessel loop is tion on lymphatics around the vessel is necessary
applied to the identified GSV (Fig. 18.2). There during dissection to prevent complications includ-
exist several small branches to GSV during dis- ing lymphocele. Further dissection in the cranial
direction would reveal saphenofemoral junction
encountering the femoral vein. Further dissection
proximally to the saphenofemoral junction to
expose the femoral vein is carried out, then vessel
loop and vascular tourniquet are applied to the
femoral vein after dissection from the surround-
ing connective tissues (Fig. 18.3). The femoral
vein below and distal to the saphenofemoral junc-
tion is dissected and applied with a vessel loop.
Meticulous care is required for the dissection of
the posterior side of the femoral vein to not to
injure small branches draining into the femoral
vein on the posterior side because profuse bleed-
Fig. 18.1 Mark the imaginary route of femoral vein ver- ing and difficult hemostasis could occur. Distal
tically around 3 cm medially to pulsating femoral artery
femoral vein and GSV are fastened tightly with
vessel loops to occlude blood flow. After all the
vessels are dissected and separated, a vascular
clamp is directly applied around the femoral vein
distal to the saphenofemoral junction, and a fas-
tened vessel loop is applied to GSV to occlude the
entire inflow into the femoral vein (Fig. 18.4). The
vertical incision on the femoral vein at 2 cm prox-
imal to the saphenofemoral junction is made
(Fig. 18.5), followed by the insertion of cannula
sized around 24 Fr–28 Fr depending on the diam-
eter of the femoral vein. At this moment, the
opposite end of the inserted cannula is occluded
Fig. 18.2 Dissected GSV is positioned in the lateral trac- with a tube clamp. Tip of the introduced cannula
tion with a vessel loop is placed around the left common iliac vein
106 G.-W. Song

Fig. 18.4 GSV is vertically incised to make an entrance Fig. 18.6 The vascular tourniquet is applied at the appro-
for a cannula into the femoral vein priate location after the cannula [tube] is inserted into the
femoral vein

1.0 L/min. For the bypass of portal flow, an RMI

catheter is introduced into the main portal vein
which is divided as high in the hilum as possible.
In the case of well-developed portosystemic col-
lateral, bypass from portal flow might not neces-
sarily be needed.

18.2.2 Removal Method

After reperfusion of the transplanted liver,

Fig. 18.5 Immediately before introducing the cannula removal of the veno-venous bypass is carried out.
into the femoral vein, blood flow from the distal part of
the femoral vein is blocked using a vascular clamp At first, the pump line is disconnected by cutting
the cannula between the two tube clamps applied
to the distal end of the cannula, followed by turn-
directly below the IVC and secured via the tight- ing off the pump machine. The pump line con-
ening of the vascular tourniquet applied [hung] nected to the cannula inserted into the internal
beforehand. In adults, the proper length of the jugular vein is also disconnected. The cannula
cannula inserted into the femoral vein is around introduced into the femoral vein is removed after
13–15 cm. The cannula is flushed with heparin to releasing the vascular tourniquet followed by
wash out remaining air bubbles inside and re- tightening of the vascular tourniquet right after
clamped with a tube clamp. The pump line is con- letting gush out of some blood from the femoral
nected to the bypass machine and the return pump vein. Vascular clamp holding the distal femoral
line is introduced to the catheter inserted into the vein and vessel loops fastening GSV is released,
internal jugular vein. Cannula inserted into the followed by gushing out the stagnant blood and
femoral vein is also connected to the pump line thrombus during clamping of the femoral vein,
and veno-venous bypass is started after releasing through compressing the thigh and leg distally.
the tube clamp (Fig. 18.6). The pump speed is After removal of stagnant blood and thrombus,
maintained between 3000 and 3500 RPM (revolu- the incised part of the femoral vein is partially
tions per minute) to keep blood flow from 0.8 to clamped with a vascular clamp and sutured.
18 Recipient Hepatectomy with Venovenous Bypass 107

18.2.3 Pros and Cons of Veno-Venous the level of the right and left portal veins as high
Bypass in the hilum as possible. Suprahepatic IVC and
infrahepatic IVC are clamped and divided while
18.2.3.1 Pros taking care to retain as much as possible for suf-
During the anhepatic phase after total hepatec- ficient length, and the diseased liver is removed
tomy with resection of retrohepatic IVC after the (Fig. 18.7). The diameter of suprahepatic IVC is
suprahepatic IVC and the infrahepatic IVC are prepared and widened by opening the right, mid-
clamped, veno-venous bypass helps in maintain- dle, and left hepatic veins into a common cloaca
ing hemodynamic stability and provides a longer of the IVC (Fig. 18.8).
anhepatic time for better surgical performance in
implantation of the graft liver. Also, during the
anhepatic phase, veno-venous bypass helps to
reduce the incidence of post-transplant renal dys-
function by maintaining stable hemodynamic
with sufficient blood flow to the kidney. The
maintenance of mesenteric blood flow during the
anhepatic phase can enable avoiding bowel con-
gestion and edema.

18.2.3.2 Cons
Incidence of complications associated with veno-­
venous bypass has been reported around 10–30%,
which includes unintended dislocation of the Fig. 18.7 Total hepatectomy is performed along with ret-
cannula, thrombosis in pump line with pulmo- rohepatic IVC
nary embolism, air embolism, etc. Lymphocele,
hematoma, infection, and nerve damage around
the dissected GSV and femoral vein could also
occur as complications. Additionally, total opera-
tion time might be prolonged due to the installa-
tion time for the veno-venous bypass.

18.3 Total Hepatectomy

After the installation of the veno-venous bypass

is completed, total hepatectomy is done. At first,
both the hepatic arteries are ligated and divided.
Fig. 18.8 Septa between the main hepatic veins entering
The main portal vein is clamped and divided at suprahepatic IVC are cut and the diameter is widened
 Implantation of the Deceased
Donor Liver Graft 19
Young Kyoung You

Abstract Keywords

A longer ischemic time of more than 6 h has Ischemic time · Brain death liver transplanta-
an obvious negative effect on the outcome of tion · Piggyback technique · Reperfusion
brain death liver transplantation. Liver graft Anhepatic · Coagulation · Duct-to-duct
procured at a geographically longer distance anastomosis
needs more time to recover graft function in
general. Most centers prefer the piggyback
technique for convenience. However, in some A longer ischemic time of more than 6 h has an
specific cases such as Budd-Chiari syndrome, obvious negative impact on the outcome of liver
extracorporeal circulation during the anhe- transplantation.
patic phase has to be considered for the main- The Piggyback technique is the general trend.
tenance of hemodynamic stability.
Recipient hepatectomy followed by out-
flow (inferior vena cava) and portal vein 19.1 Anastomosis of IVC (Inferior
reconstruction then reperfusion of the graft is Vena Cava)
performed under serious monitoring of an
individual. Restoration of coagulation func- In the case of retrohepatic IVC removal, end-to-­
tion of the liver varies according to the graft end reconstruction at both the parts of the IVC
condition and arterial reconstruction of the had to be made promptly to restore systemic cir-
graft required prior to control minor bleeders. culation using 4-0 or 5-0 monofilament nylon. At
Attempt to meticulous bleeding control before this moment, veno-veno bypass procedure is
entire vascular reconstruction seems ineffi- unnecessary due to established porto-systemic
cient. Duct-to-duct anastomosis in biliary collaterals in most of the end-stage liver diseases.
reconstruction is a general trend. The anastomosis can be performed either end-­
to-­side or side-to-side fashion. Occasionally end-­to-­
side reconstruction has to be completed in the deep,
narrow operation field. And recipient’s suprahepatic
Y. K. You (*) IVC stump is prone to the withdrawal of the cross-
Division of Hepatobiliary-Pancreas Surgery and Liver clamp; therefore, side-to-side anastomosis tech-
Transplantation, Department of Surgery, Seoul St.
niques are rather preferred recently (Fig. 19.1).
Mary’s Hospital, College of Medicine, The Catholic
University of Korea, Seoul, South Korea However, one might have difficulties in the opera-
e-mail: [email protected] tion field securement in the huge graft right liver.

© Springer Nature Singapore Pte Ltd. 2023 109

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_19
110 Y. K. You

cold preservation solution, various metabolites in

the liver graft, and congested intestinal inflows to
systemic circulation could evoke such kind of
undesirable events.
If necessary, steroids and immunoglobulins
are injected at this moment. Undetected hemosta-
sis from the major vessels during the procure-
ment and bench procedure should be identified
immediately.

19.4 Anastomosis of the Hepatic

Artery

Right after the control of bleeders from the ves-

sels, management of minor bleeders and blood
oozing focus should be postponed to the restora-
tion of hepatic arterial supply. Perfect hemostasis
could not be obtained despite all the efforts. After
Fig. 19.1 Side-to-side anastomosis for graft and recipi- complete vascular reconstruction, all the efforts
ent inferior vena cava in liver transplantation to attain hemostasis should be done. The arterial
anastomosis can be performed at the junction of
the gastroduodenal artery and common hepatic
19.2 Anastomosis artery with minimal tissue dissection (Fig. 19.2).
of the Portal Vein In case of insufficient arterial supply from the
common hepatic artery or gastroduodenal artery
Anastomosis under the accurate configuration of because of various reasons such as severe athero-
the portal axis is the key point of portal inflow matic plaque, arterial denuding due to repeated
securement. Another important issue is the avoid- previous arterial manipulation, etc., interposition
ance of redundancy of both the parts of portal graft from the infrarenal aorta could be the alter-
veins. Postoperative graft enlargement makes native method for reconstruction of the hepatic
easy angulation of the anastomotic line, which artery. Preventing kinking and excessive bending
might evoke the portal inflow disturbance. is an essential component of successful arterial
Also, we need to make enough anastomotic
growth factors to avoid mechanical stricture of the
portal vein. Portal vein anastomosis is performed
either with 6-0 or 5-0 monofilament nylon suture.

19.3 Reperfusion

Reperfusion is the highlight of liver transplanta-

tion. At this moment, aggressive monitoring and
management by the anesthesiologists should be
guaranteed. Not a few cases experience hemody-
namic instability and cardiac dysrhythmia at this
Fig. 19.2 The arterial anastomosis of graft liver at the
stage. Sometimes an episode of cardiac arrest junction of the gastroduodenal artery and common hepatic
could develop. Abrupt gushing materials such as artery of the recipient in liver transplantation
19 Implantation of the Deceased Donor Liver Graft 111

reconstruction. Transmesocolic and retrogastric 19.6 Addendum

route is recommended for this purpose.
As the arterial interposition graft, the cadav- The coagulation status of the recipient restores
eric iliac arterial graft of artificial graft such as insidiously after successful implantation of the
PTFE or Dacron graft can be used. graft. Thorough hemostasis before abdominal
wound closure has to be considered as an essen-
tial process in liver transplantation. Events of
19.5 Bile Duct Anastomosis minor capsular injury during organ procurement
procedure could progress to huge graft hepatic
Duct-to-duct anastomosis has been widely subcapsular hematoma or bleeding to free perito-
accepted as a routine procedure in bile duct neal space. Various hemostatic agents such as
reconstruction during liver transplantation. In fibrin glue or gel, powder, and collagen patch
contrast to the bile duct to the enteric anastomo- coated with fibrinogen are effective in general.
sis, we expect fewer morbidities related to Transabdominal drainage tubes are placed in the
ascending cholangitis. dependent portion around the graft liver, sub-
Furthermore, duct-to-duct reconstruction phrenic spaces, Morrison’s pouch, and gastrohe-
allows prompt endoscopic approach in postoper- patic junction. Drainage tubes are placed through
ative complications. Monofilament continuous the main wound rather than the stab wound to
running suture materials are used in the anasto- avoid bleeding at the stabbing area under
mosis, and interrupted sutures can be selected in improper hemostatic conditions of the recipient.
the anticipating stricture, but the outcomes of the Meticulous layer by layer wound closure can
bile duct stricture are reported similar to that of make dead space free abdominal wound.
the continuous suture. T-tube is not recommended
in general.
 Part III
Living Donor Liver Transplantation
 Donor Right or Extended Right
Hemihepatectomy 20
Jae-Won Joh and Gyu-seong Choi

Abstract ter. The degree of fatty liver should not be severe,

and the donation would be considered inappro-
Unlike conventional hepatic resection, donor
priate if the anatomical structure impairs the
surgery of living donor liver transplantation
donor’s safety. It is preferable to have no tumor or
must preserve the flow of blood to the graft
serious cardiovascular disease, the pure relation-
and the remaining liver. Resection should also
ship between the donor and recipient should be
maintain sufficient length to facilitate anasto-
proven, and the compatible ABO blood type
mosis during the recipient’s surgery. Of
should be appropriate. If the ABO blood type is
course, the most important thing in surgery is
incompatible, transplantation can be performed
the safety of the donor.
after pretreatment, but long-term results need to
be considered.
Keywords

Donor surgery · Right hepatectomy

Extended right hepatectomy · Liver 20.2 Graft Selection
transplantation · Liver graft
Although controversial, the minimum remaining
liver volume to ensure the safety of the donor
20.1 Donor Selection should be at least 30–35% of the total liver vol-
ume, and the remaining liver should not be asso-
The donor must be medically healthy, including ciated with problems like congestion or ischemia.
the psychiatric part, and must be willing to donate In order not to cause congestion in the remaining
liver voluntarily. The donor must be of an age liver, the case of selecting an extended right
capable of making decisions, and the criteria for hepatic resection in which the middle hepatic
determining the age may vary from center to cen- vein is excised together should be limited to the
presence of another hepatic vein through which
Supplementary Information The online version con- blood flow of segment 4 is drained. In a graft per-
tains supplementary material available at https://doi. formed by conventional right hepatic resection,
org/10.1007/978-­981-­16-­1996-­0_20.
the venous blood flow to the anterior section may
be blocked and the volume of the functioning
J.-W. Joh (*) · G.-s. Choi parenchyma may be reduced depending on the
Department of Surgery, Samsung Medical Center, anatomical structure. In this case, liver transplan-
Sungkyunkwan University School of Medicine, tation using a modified right liver graft in which
Seoul, South Korea

© Springer Nature Singapore Pte Ltd. 2023 115

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_20
116 J.-W. Joh and G.-s. Choi

the branch of the middle hepatic vein is recon- liver, checking the inferior vena cava (IVC) in
structed using cryopreserved or artificial vessels the upper part of the liver, and dissect the groove
can be selected. between the right hepatic vein and the middle
hepatic vein. The coronary and triangular liga-
ments between the right liver and the diaphragm
20.3 Incision of Operation are divided. From the top, the right hepatic vein
is separated by ligating the IVC ligament start-
As with conventional hepatectomy, the donor lies ing under the origin of the right hepatic vein, and
in the supine position, and one can fold both the from the bottom, dissection is done to the groove
arms or one arm toward the body as needed. between the caudate lobe and IVC. The donor’s
Inverted T-shaped incision which is traditionally liver without a history of inflammation usually
used in the right hepatic or enlarged right hepatic does not have adhesion with the surrounding
resection or midline extension from the bilateral organs, but if the right adrenal gland and hepatic
subcostal incision, midline extension from the parenchyma are adhered to each other, it is rec-
right subcostal incision, J-shaped incision, or ommended to ligate the adrenal gland during
inverted L-shaped incision is mainly used. separation from the liver to prevent bleeding.
Recently, there have been many young donors for Although there is no particular problem in ligat-
living donor liver transplantation, and the inci- ing and separating the small right inferior hepatic
sion tends to become smaller. So, there are cases vein that meets while mobilizing the IVC and the
where an upper midline incision or right sub-­ right liver, ligation is recommended so that the
costal incision is made. The selection of the inci- right inferior hepatic vein of more than 5 mm
sion may vary depending on the experience and should be delayed to the brink of liver extraction.
preference of the operator, but the most important This is because if these veins play an important
thing is the donor’s safety and an appropriate sur- role in the outflow of blood, it may be necessary
gical field of view that does not damage the graft. to drain this flow by anastomosis with the recipi-
Also, the incision should be large enough to ent’s IVC during transplantation. If these veins
allow the graft to be taken out of the body. After are ligated before parenchymal resection, con-
securing the incision, an appropriate retractor is gestion of the liver at the site can occur and dam-
used to secure the field of view. The retractor can age the graft. The IVC ligament, which is located
be selected differently depending on the opera- just below the right hepatic vein, surrounds the
tor’s preference or the environment of the center. IVC, and careful dissection must be done
However, since the location of the liver is under because bleeding can occur if dissection goes the
the ribs, it is important to use a retractor that can wrong way. If the length of the IVC ligament is
secure the field of vision by sufficiently retract- long, suture ligation must be performed. When
ing the ribs toward the patient’s head. the right hepatic vein is exposed after full liver
mobilization, a suspension umbilical tape is
placed between the right hepatic vein and the
20.4 Liver Biopsy and Liver middle hepatic vein (Fig. 20.1). This is for the
Mobilization hanging maneuver, which helps accurate paren-
chymal resection and reduces bleeding in the
After laparotomy, the ligament of teres is excised deep areas. If the frozen liver section examina-
followed by installing the retractor. The overall tion reveals fatty liver, transplantation is decided
left and right ratio of the liver and the condition based on the type of fatty liver (macrovesicular
of the liver are visually checked, and liver biopsy fatty liver), degree (more than 30%), size of the
for the frozen section is performed. Moving remaining liver, and the condition of the
upward, separate the falciform ligament from the recipient.
20 Donor Right or Extended Right Hemihepatectomy 117

Fig. 20.1 The mobilization of the right liver with the pre-
Fig. 20.2 After cholecystectomy, the right hepatic artery
served large right inferior hepatic vein. The suspension
(red vessel loop), right portal vein (blue vessel loop), and
umbilical tape is placed
common bile duct (yellow vessel loop) are exposed

or running in front of the common bile duct.

20.5 Cholecystectomy Therefore, it is necessary to obtain sufficient
and Dissection information about this anatomy before surgery.
of the Hepatic Hilum The dissection and sufficient mobilization of the
portal vein should be performed while the ana-
Cholecystectomy and dissection of the hepatic tomical structure is identified by the preoperative
hilum should be performed while the anatomical examination. If necessary, the length of the portal
structure is identified through preoperative exam- vein can be sufficiently obtained by ligating a
inations such as CT and MRCP. Because there small branch running to the caudate lobe
may be cases with anatomical variations in the (Fig. 20.2).
presence of the accessory duct running around
the gallbladder, careful dissection of the gallblad-
der should be done. Intraoperative cholangiogra- 20.6 Intraoperative Ultrasound
phy may be performed to check the path of the
bile duct and select the duct resection site. Careful When the dissection of the hepatic hilum is com-
dissection of the hepatic duct must be done along plete, the border between the right and left lobe is
with checking the path of the common bile duct, checked while the blood flow in the right hepatic
common hepatic duct, and right hepatic duct. At artery and the right portal vein is temporarily
this time, the tissue around the bile duct should blocked using a vascular clamp (Fig. 20.3). After
be preserved to the maximum extent possible so marking this boundary with an electric cautery
that the blood flow in the bile duct is well main- device, the relationship between the middle
tained. The right hepatic artery must be dissected hepatic vein and the parenchymal resection plane
to a sufficient length until the middle or left can be checked using ultrasound. The resection
hepatic artery appears and to the start of the intra- plane is located on the right side of the middle
hepatic level so that it is not damaged during the hepatic vein in case of performing a right hepa-
right bile duct resection. Depending on the ana- tectomy, and the branch of the middle hepatic
tomical variation, there may be a right hepatic vein draining the anterior section can be con-
artery on the right side of the common bile duct, firmed by ultrasound (Fig. 20.3). The resection
118 J.-W. Joh and G.-s. Choi

Fig. 20.3 After marking the boundary between the right and left lobes with vascular clamp and electric cauterization,
the location of the resection surface and the middle hepatic vein branch is confirmed using ultrasound

surface should be on the left side of the middle method, the resection is easy with the resection
hepatic vein in case of performing extended right surface located higher than the heart which pre-
hepatectomy, and it should be confirmed that vents the bleeding. Prepare to implement the
another hepatic vein draining segment 4 exists. Pringle’s maneuver in case of unexpected bleed-
The resection line on the hilum side should be ing, and start actual resection [1]. Parenchymal
positioned slightly to the left than in conventional resection is performed using an ultrasonic dissec-
right hepatectomy to prevent the right hepatic tor (Fig. 20.4). At this time, microbleeding can be
duct from exfoliating too much. prevented by using a bipolar coagulator for the
resection surface and the surgical field of view
can be better secured thereby making the opera-
20.7 Hepatic Parenchymal tion more comfortable. In the case of right hepa-
Resection tectomy that does not include the middle hepatic
vein, a branch of this vein measuring 5 mm or
Before resecting the liver parenchyma, place the more that flows from the anterior section should
gauze behind the right liver so that the resection be excised using a clip that can be removed and
line is centered. When using a small incision then restored on the bench procedure [2]. A beat-
especially, a midline incision, it is better to place ing middle hepatic vein can be identified at the
the gauze and move the liver to the left rather graft side in case of extended right hepatic resec-
than tilting the patient. Two or three pairs of tow- tion, or at the residual liver side in case of con-
ing threads are hung on both sides of the cutting ventional right hepatic resection. This middle
line. If the liver is sufficiently lifted through this hepatic vein can guide the resection surface.
20 Donor Right or Extended Right Hemihepatectomy 119

20.8 Resection of Hepatic Duct

When the hepatic parenchyma is sufficiently sep-

arated and the right hepatic duct is exposed, the
duct is resected which may be assisted by intra-
operative cholangiography (Fig. 20.5a). Before
resection, the right hepatic artery and the right
portal vein are pulled downwards using a vessel
loop to prevent unexpected damage caused by
sharp instruments used during resection
(Fig. 20.5b). After setting the starting site of the
right hepatic duct and a virtual resection line, the
resection is started in a direction perpendicular to
Fig. 20.4 Resect the parenchyma using an ultrasonic dis-
sector (CUSA®) and cauterize the bleeding area on the the right hepatic duct. Starting the resection on
resection surface using a bipolar coagulator the right side of the right hepatic duct is unsuit-

a b

c d

Fig. 20.5 (a) Bile duct variation (type C) confirmed by Resection in the vertical direction of the running path of
preoperative cholangiography. (b) Using a vessel loop, the right hepatic duct. (e) Closing the remaining bile duct
pull the right hepatic artery and right portal vein toward with suture-ligation. The hepatic duct looks like a pig
the leg. (c) The anterior direction of the hepatic duct (ven- nose on the side of the graft
tral direction of the donor) is excised perpendicularly. (d)
120 J.-W. Joh and G.-s. Choi

e placed in advance above the right hepatic artery

and portal vein. This not only reduces bleeding
but also appreciably helps in accurate hepatic
resection.

20.10 Extraction of the Graft

When the parenchymal resection is completed,

the graft is extracted in a state ready for perfu-
sion. Heparin is injected intravenously before
vascular ligation. In some centers, heparin is
injected during graft perfusion. If the preserved
Fig. 20.5 (continued) right inferior hepatic vein exists, it is resected
first. At this time, bite the IVC sufficiently with a
able because the early-branched anterior and pos- vascular clamp to obtain a vein of sufficient
terior hepatic ducts can be resected separately. length. The vessels are ligated or clamped and
Start resection in the perpendicular direction, then resected in the order of the right hepatic
confirm the safety of the left hepatic duct and the artery, the right portal vein, and the right hepatic
direction of the anterior and posterior hepatic vein. After the graft is handed over to the perfu-
ducts, and then proceed with the total resection. sion team, the blood vessels bitten by the vascular
The resection of the right hepatic duct is per- clamp are suture-ligated.
formed in a direction vertical to the driving direc-
tion of the duct in order to preserve blood flow
around the duct to the maximum extent possible References
(Fig. 20.5c, d). It is better to use suture ligation
rather than using electric cauterization for micro- 1. Park JB, Joh JW, Kim SJ, et al. Effect of intermittent
hepatic inflow occlusion with the Pringle maneuver
bleeding which occurs at this time to preserve during donor hepatectomy in adult living donor liver
blood flow around the bile ducts (Fig. 20.5e). transplantation with right hemiliver grafts: a prospec-
tive, randomized controlled study. Liver Transpl.
2012;18:129–37.
2. Akamatsu N, Sugawara Y, Kaneko J, et al. Effects of
20.9 Hanging Maneuver middle hepatic vein reconstruction on right liver graft
reconstruction. Transplantation. 2003;76:832–7.
After resection of the hepatic duct, the caudate
lobe and the remaining deep hepatic parenchyma
are resected after pulling out the suspension tape
 Donor Left Hemihepatectomy
21
Kyung-Suk Suh and Suk Kyun Hong

Abstract metic needs of donors have recently led to

increased use of the minimally invasive donor
During donor hepatectomy in living donor
hepatectomy.
liver transplantation, donor’s safety and graft
quality preservation must be ensured at the
same time. There are several tips and pitfalls to
21.2 Liver Mobilization
consider in donor left hepatectomy. Recently,
minimally invasive techniques including pure
The falciform ligament is dissected from the liver
laparoscopic technique have increasingly been
and up toward the inferior vena cava in order to
adopted for major donor hepatectomy.
expose the middle and left hepatic veins. Next, the
space between the right and middle hepatic veins
Keywords
is dissected to expose the inferior vena cava. The
Donor hepatectomy · Living donor liver left liver is then dissected from the diaphragm
transplantation · Left hepatectomy while dissecting the coronary ligament using elec-
Laparoscopy · Minimally invasive trocautery. The left triangular ligament at the end
of the left liver is dissected from the diaphragm.
The left lateral section of the liver is moved to
21.1 Incision and Exposure the right using a malleable retractor. The lesser
sac is exposed while applying traction on the
For left hepatectomy, the Mercedes-Benz inci- stomach in the direction of 5 o’clock. If the left
sion was preferred traditionally. However, an hepatic artery branches off the left gastric artery,
inverted L incision has now come to be used caution must be taken not to damage the vessel.
more frequently. Further, the functional and cos- The left lateral section is flipped right, while the
hepatogastric ligament is dissected to expose the
ligamentum venosum located between the cau-
Supplementary Information The online version con- date lobe and the left lateral section. The liga-
tains supplementary material available at https://doi. mentum venosum is then ligated and divided
org/10.1007/978-­981-­16-­1996-­0_21.
near the left hepatic vein. The tissues surround-
ing the left hepatic vein are dissected cleanly to
K.-S. Suh (*) · S. K. Hong prepare for the hanging tape to pass between the
Department of Surgery, Seoul National University middle and left hepatic vein trunk and the infe-
College of Medicine, Seoul, South Korea rior vena cava.
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 121

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_21
122 K.-S. Suh and S. K. Hong

Tip: Before mobilizing the left liver, place gauze hepatic vein and the inferior vena cava to create
under the left liver toward the diaphragm to a tunnel for the hanging tape (Fig. 21.1a). If
reduce the risk of damaging the intestines or enough space has not been created in one direc-
the spleen with electrocautery and to facilitate tion, insert the right-angle clamp toward the
the dissection of the liver from the diaphragm. opposite direction to secure enough space. Once
The first assistant can also press on the the tunnel has been created, hold the tape sling at
patient’s intestines backward and to the left the end of the right-­ angle clamp and pass it
with a malleable retractor in order to facilitate between the right hepatic vein and the middle
visualization during ligation of the left trian- hepatic vein as well as under the middle and left
gular ligament. hepatic veins (Fig. 21.1b); the hanging tape
should pass above the inferior vena cava. As
there is risk of massive bleeding from inferior
21.3 Placement vena cava damage, the right-angle clamp should
of the Hanging Tape be manipulated carefully and slowly.

The right-angle clamp is placed between the

right and middle hepatic veins. The end of the
clamp is inserted into the space between the left

a b

Fig. 21.1 Preparing for the hanging maneuver. (a) A and the middle hepatic vein as well as under the middle
clamp between the left hepatic vein and the inferior vena and left hepatic veins
cava. (b) A nelaton tube between the right hepatic vein
21 Donor Left Hemihepatectomy 123

21.4 Cholecystectomy Tip 2: Temporarily ligate the left and middle

hepatic arteries and left portal vein using ves-
This is not much different from regular cholecys- sel loops or vascular clamps to observe the
tectomy. Ensure that the remaining cystic duct change in color of the left liver.
has sufficient length so that the course of the bili-
ary duct can be confirmed using a probe or so that
a contrast agent can be injected into the biliary 21.6 Resection of the Liver
duct for intraoperative cholangiogram. Parenchyma

Use CUSAⓇ (Cavitron Ultrasonic Surgical

21.5 Hilar Dissection Aspirator) to dissect the liver parenchyma along
and Demarcation the border between the left and right sides of the
for Transection liver. Follow the midplane of the liver carefully
while avoiding Gleason branches to easily dissect
Confirm any changes in the hepatic artery, portal the parenchyma. Ligate any middle hepatic vein
vein, or bile duct in preoperative computed branches draining the right liver along the
tomography (CT) and magnetic resonance imag- ­resection plane. Dissect the parenchyma around
ing (MRI) before proceeding with surgery. To the hilum to expose the hilar plate.
begin, dissect away the tissues surrounding the Tip: Use ultrasound to periodically confirm
left hepatic artery to confirm where the left the position of the middle vein and ensure that
hepatic artery bifurcates off the common hepatic the resection plane is not skewed toward the right
artery. Carefully dissect the tissues to avoid dam- of the middle vein.
age to the hepatic artery. In addition, be careful to
prevent heat damage to the artery from excessive
use of electrocautery. Dissect the surrounding tis- 21.7 Resection of the Left
sues around the middle hepatic artery to expose Bile Duct
it. Divide the lesser sac and expose the caudate
lobe, then ligate the exposed branches of the por- Pass the probe into the long tail of the remnant
tal vein that enter the caudate lobe. Once the tis- cystic duct from cholecystectomy to locate the
sues are surrounding the left hepatic artery and border between the right and left bile ducts
the posterior aspect of the middle hepatic artery, (Fig. 21.2). After applying a tagging suture, make
the left portal vein is easily exposed. a small incision to the distal left bile duct.
Unlike the crimson color of the surface of the Re-confirm the location of the branches of the left
right liver, the left liver can change to a dark red and right bile ducts before proceeding with com-
color with the temporary blockage of inbound plete division of the left bile duct. Use continuous
blood flow. This turns into a border between the
left and right liver. Mark this border on the sur-
face of the liver using electrocautery and use it as
a reference line for the resection of the left liver.
This border will enter between the right and left
hepatobiliary ducts. Subsequently, release the
vessel loop or vascular clamp to maintain perfu-
sion into the liver during liver resection.

Tip 1: Palpate intraoperatively to obtain a general

overview of the course of the right, left, and
middle hepatic arteries. Fig. 21.2 Bile duct probing
124 K.-S. Suh and S. K. Hong

suturing with nonabsorbable sutures to close the 21.9 Vessel Dissection and Liver
stump of the bile duct to prevent distortion of the Retrieval
bile duct and leakage of bile fluids. Finally, sepa-
rate and ligate the branches of the portal vein and Ligate the left hepatic artery at the point where
dissect and ligate the hilum gradually. the left hepatic artery diverges from the proper
hepatic artery. Divide the left hepatic artery and
Tip 1: Apply superior-inferior traction on the confirm regurgitant flow. If the middle hepatic
suture site of the bile duct during suturing to artery originates from the right hepatic artery,
prevent distortion of the bile duct. dissect the middle hepatic artery near its origin
and divide it. Use a vascular stapler or a vascular
clamp to divide the left hepatic vein as closely as
21.8 Resection of the Remaining possible to the inferior vena cava. Leave the
Liver Parenchyma hepatic artery, portal vein, and hepatic vein on the
graft side as long as possible without damaging
Bring the lower end of the hanging tape out supe- the vascular structure of the donor.
rior to the left hepatic artery and portal vein and
use the hanging maneuver to dissect the liver Tip 1: When dividing the portal vein, apply a vas-
parenchyma (Fig. 21.3). As there are multiple cular clamp vertically to avoid narrowing of
Gleason branches that cross the resection plane the left portal vein.
of the caudate lobe, make sure to ligate them Tip 2: Hold the surface of the liver with gauze to
carefully. Visualize the vessel structures by ade- avoid damage or slipping when removing the
quately dissecting the tissues surrounding the graft from the abdominal cavity of the donor.
inferior vena cava, the middle hepatic vein, and
the origin of the left hepatic vein.
21.10 Bench Operation
Tip: As the remaining liver parenchyma is located
deep within the abdominal cavity, using the The left liver graft should be perfused using
hanging maneuver can reduce bleeding and organ preservation fluid that has been chilled to
keep the resection plane of the liver paren- approximately 4 °C through the portal vein. A
chyma straight. syringe filled with this preservation fluid can be
used to irrigate the left hepatic artery and the left
bile duct. The structures of the blood vessel and
biliary duct can be confirmed in this way, and the
graft can be trimmed to optimize anastomosis.

21.11 Pure Laparoscopic Donor

Hepatectomy

Until very recently, living donor hepatectomy has

Fig. 21.3 Transecting liver parenchyma in the deep been performed under conventional laparoto-
portion mies. Compared to conventional laparotomies,
21 Donor Left Hemihepatectomy 125

laparoscopic surgery leads to better cosmetic out- ious angles is particularly important in laparo-
comes, shorter hospital stays, and less pain. scopic hepatectomy because of the relatively
Further, various studies have shown that postop- small space available for instrument manipula-
erative complication rates are reduced in laparo- tion. To maximize the visualization and depth of
scopic surgery. Along with these benefits, due to perception, a 3D flexible laparoscopy is pre-
the increased experience and knowledge in lapa- ferred. To make the border between the right and
roscopic surgery in the era of striving toward the left liver more prominent and find a safe area
minimally invasive surgery, pure laparoscopic for resection through real-time confirmation of
donor hepatectomy is also being performed at the location of the bile duct, indocyanine green
some centers. near-infrared fluorescence can be used (Fig. 21.4).
Laparoscopic surgery differs from traditional Following the resection, the graft can be removed
surgery in that the position of the trocar is fixed, using an incision made horizontally above the
and the operator visualizes the field from the pubic symphysis, which can be covered by under-
patient’s lower limb area (caudal view). wear and is therefore esthetically preferable.
Manipulating the scope to obtain views from var-

Fig. 21.4 Usage of indocyanine green near-infrared fluorescence

 Living Donor Liver Graft
Back-­Table Procedure 22
Choon Hyuck David Kwon and Gyu-seong Choi

Abstract 22.1 Hepatic Vein Reconstruction

Trimming is performed with a focus on the
reconstruction of blood flow. If two or more The goal of hepatic vein reconstruction is to pre-
portal veins or bile ducts are present due to vent congestion of the graft by preventing
anatomical variations, venoplasty or ducto- obstruction of the venous outflow.
plasty can be performed at the back-table to
combine them. In this chapter, we will intro-
duce a method of reconstructing the blood 22.1.1 Securing Blood Flow
flow of the graft and explain the reconstruc- in the Anterior Section
tion of the portal vein and bile duct with ana- of the Modified Right Liver
tomical variations. The reconstruction method Graft
may differ depending on the preferences of
the surgeon and the transplantation institute. The outflow of the anterior section of the liver
that drains into the middle hepatic vein is recon-
Keywords structed in the modified right liver graft. The
method of reconstruction differs depending on
Living donor liver graft · Back-table proce- the kind of vascular graft used (Fig. 22.1). When
dure · Hepatic vein reconstruction · Portal using a cryopreserved vein, the direction of the
vein reconstruction · Biliary reconstruction vein should be checked before anastomosis to
Venoplasty · Ductoplasty ensure that the valve does not interfere with blood
flow. As in veno-venous anastomosis, the anasto-
mosis should be prevented from narrowing the
outflow by providing appropriate growth factor
(Fig. 22.2).

Supplementary Information The online version con-

tains supplementary material available at https://doi.
org/10.1007/978-­981-­16-­1996-­0_22.

C. H. D. Kwon (*) · G.-s. Choi

Department of General Surgery, Digestive Disease &
Surgery Institute, Cleveland Clinic,
Cleveland, OH, USA

© Springer Nature Singapore Pte Ltd. 2023 127

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_22
128 C. H. D. Kwon and G.-s. Choi

a b

Fig. 22.1 (a) Reconstruction of the middle hepatic vein using cryopreserved vein. (b) Reconstruction of the middle
hepatic vein using cryopreserved artery

anastomosed to the inferior vena cava of the

recipient (Fig. 22.2).

22.1.3 Reconstruction of Blood Flow

in Left Liver Graft

The middle and left hepatic veins may appear

respectively depending on the anatomical varia-
tion in an extended left liver graft. In addition, a
conventional left liver graft may have more than
one vein. In this case, since the distance between
Fig. 22.2 Reconstructed vascular graft connected to the middle and left hepatic veins is small, the two
recipient veins are connected by angioplasty which directly
anastomoses the adjacent walls of the two veins.
22.1.2 Middle Hepatic Vein
Reconstruction of Extended
Right Liver Graft 22.1.4 Reconstruction of the Large
Right Inferior Hepatic Vein
There is a method of reconstructing the middle
hepatic vein that involves increasing the length In the case of right inferior hepatic venous resec-
using a vascular graft similar to a modified right tion involving a portion of the vena cava in donor
liver graft, while another method involves surgery, an anastomosis can be performed
reconstructing the middle and right hepatic directly on the vena cava of the recipient.
veins into one. In this case, it is recommended to However, if the right inferior hepatic vein is
use a vein graft to place a bridge connecting the short, it should be reconstructed using a vein
middle and right hepatic veins. Vein grafts can graft or another vascular graft. If the distance
also be used to make an enclosed fence to per- from the right hepatic vein of the recipient to the
form anastomosis around the blood vessels. The right inferior hepatic vein of the graft is not large,
commen trunk of the right hepatic vein and then the two veins can be reconstructed using a
reconstructed mddile hepatic vein are, then, bridge or fence vein graft.
22 Living Donor Liver Graft Back-Table Procedure 129

22.2 Portal Vein Reconstruction which can in turn prevent blood from flowing
into the narrowed portal vein. Shortening the
Portal vein reconstruction is not common in par- inside of both the portal veins and slightly length-
tial liver transplantation. In the case of type II, ening the outside is a way to prevent the direction
wherein the portal vein is triangulated, or type of blood flow from being distorted.
III, wherein the posterior portal vein branches
earlier, two portal veins appear if the right liver is
used. 22.2.2 Reconstruction Using Vein
Graft Due to Short or
Variation in the Recipient’s
22.2.1 Reconstruction Using Portal Vein
the Recipient’s Portal Vein
When using a Y-shaped graft, if the recipient’s
If the distance between the two portal veins is far, portal vein is short due to thrombus or has varia-
the recipient’s portal vein can be obtained in a tions, or if there is a large size discrepancy
Y-shape and used for reconstruction. In this case, between the two portal veins, blood may only
the anastomosis should be performed by calculat- flow to one side. There is a way to connect a suf-
ing the direction of the blood flow to the two por- ficiently large vein graft that serves as a bridge
tal veins. If one portal vein is bent or narrowed, between the two portal veins to form them into
more blood can flow to the other portal vein, one, then connect it to the portal vein (Fig. 22.3).

a b

Fig. 22.3 (a) Process of connecting two portal veins into one using a vein graft. (b) Process of reconstructing the portal
vein using the recipient’s portal vein. (c) Reconstructed portal vein after reperfusion
130 C. H. D. Kwon and G.-s. Choi

22.3 Biliary Reconstruction value. When two bile ducts of similar size are
made into one, connecting the 12 o’clock point
If more than one bile duct of the graft appears, it and 6 o’clock point of the bile duct narrows the
can either be anastomosed individually or made bile duct, which may interfere with the bile duct
into one. The size of the two bile ducts should not anastomosis. Instead, it is better to anastomose
be significantly different, and they should be at a the 2 o’clock with 10 o’clock points and the 4
distance that can be pulled to an appropriate o’clock with 8 o’clock points.
 Middle Hepatic Vein
Reconstruction of Right Liver Graft 23
Dong-Sik Kim

Abstract
23.1 Overview
Reconstruction of the middle hepatic vein is
an important part of the procedure using a The most commonly used type of graft in living
modified right lobe graft. Various modifica- donor liver transplantation (LDLT) using the right
tions are available depending on the specific lobe is the modified right lobe graft. In consider-
situation of the graft and the availability of ation of donor safety, the middle hepatic vein is
vascular grafts. It is generally recommended allowed to remain on the donor side to prevent
that tributaries larger than 5 mm in diameter congestion in the remnant left lobe. The middle
be reconstructed. In this chapter, basic con- hepatic vein for the graft is reconstructed on the
cepts and technical tips are discussed and an back-table to prevent congestion in the anterior
example is provided in the form of a video section. Through this reconstruction of the middle
clip. hepatic vein, the outcomes of LDLT using the
right lobe could be significantly improved [1].
Keywords Venous congestion in the right anterior section
has been shown to have an important effect on the
Vascular graft · Patency · Cryopreserved iliac regeneration of the graft [2]. Therefore, the
vein · Cryopreserved iliac artery · PTFE reconstructed vein must remain functional during
the initial two-week period after surgery while
the regeneration of the graft occurs rapidly.
Stenosis or obstruction of the middle hepatic vein
graft accompanied by an increase in transami-
nase is recommended to be managed through an
interventional procedure.

Supplementary Information The online version con-

tains supplementary material available at https://doi. 23.2 Judgment on the Necessity
org/10.1007/978-­981-­16-­1996-­0_23.
of Reconstructing the Middle
Hepatic Vein
D.-S. Kim (*)
Division of HBP Surgery and Liver Transplantation, The reconstruction of the middle hepatic vein
Department of Surgery, Korea University College of
Medicine, Seoul, South Korea depends on the extent to which the venous blood
e-mail: [email protected] from the right anterior section is drained into it.

© Springer Nature Singapore Pte Ltd. 2023 131

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_23
132 D.-S. Kim

Therefore, the preoperative computed tomogra- used for reconstruction and the physical proper-
phy of the donor should be closely reviewed to ties thereof, and the location of the branch already
obtain the sizes and locations of the tributaries, existing in the blood vessel graft should all be
particularly V5 and V8, that drain into the middle considered together. In addition, there is a differ-
hepatic vein. During donor surgery, if the right ence in the reconstruction method depending on
hepatic artery is blocked with a bulldog clamp whether the right hepatic vein and the middle
after the parenchyma and tributaries of the mid- hepatic vein are anastomosed separately or as a
dle hepatic vein have been cut, the degree of con- single one at the time of anastomosis, thus neces-
gestion in the right anterior section can be directly sitating close communication between team
checked [3]. The graft to recipient weight ratio members.
(GRWR) of the graft or the degree of steatosis The anastomosis should be initiated after con-
may also be considered. In general, reconstruc- sidering the overall design in front of the liver
tion is recommended when the diameter of the graft and the vessel graft to be used for recon-
tributary entering the middle hepatic vein is struction such that a natural angle can be formed
5 mm or more. in order to avoid twisting or folding of the vessel
graft.

23.3 Blood Vessels Used

for Reconstruction 23.5 Anastomosis Tips (See Video
23.1)
Various blood vessels have been used to recon-
struct the middle hepatic vein. Because the pro- 1. The blood vessels are arranged according to
cess involves reconstructing the venous system the design previously thought of. It does not
with low blood pressure, vascular grafts that can matter if the blood vessel to be used is a type
reflect the original characteristics of the middle that maintains the lumen itself, such as an
hepatic vein that deliver the lower pressure state artery or PTFE, but if the material is large
of the right atrium and the central vein more than and cannot maintain its lumen by itself, such
the durability of the blood vessel are preferred, as an iliac vein, distortion of the vessel graft
such as cryopreserved iliac vein. However, its that occurs while placing and determining
supply is limited. Good results have been reported the anastomosis position can be minimized
using alternatives such as cryopreserved iliac by filling the lumen with heparinized saline.
arteries, a greater saphenous vein from the recipi- 2. If a vein is used as a vessel graft for recon-
ent, a left portal vein taken from the removed struction, check if there are any valves inside,
recipient’s liver, or an artificial vein such as and remove any found.
polytetrafluoroethylene (PTFE) [4–6]. 3. The order of the tributaries to be anasto-
mosed to the vessel graft needs to be deter-
mined in consideration of the location and
23.4 Technical Considerations direction of the recipient's middle hepatic
for Reconstruction vein stump. The order needs to be deter-
mined to avoid any suffering in anastomosis
The goal of reconstruction is to maintain the from the previously made anastomosis. If the
blood flow naturally, but each liver graft has dif- tributaries are not lined up straight, it is con-
ferent locations of the openings of the tributaries venient to start the anastomosis from the one
of the middle hepatic vein exposed on the cut sur- located in the middle.
face, and they may also have different numbers. 4. Hang the 6-0 prolene double-arm suture at
Further, the positional correlation with the right both ends of the opening of the tributary to
hepatic vein, the existence of the right inferior be anastomosed following the direction of
hepatic vein, the type of blood vessel graft to be the blood vessel to be reconstructed.
23 Middle Hepatic Vein Reconstruction of Right Liver Graft 133

5. Make a hole in the wall of the vessel graft the reconstruction of the middle hepatic vein;
with a diameter equal to or slightly larger sometimes, this allows unnecessary bleeding
than the inner diameter of the tributary. At from the cut surface or venous reconstruction site
this time, if using artery or PTFE, do not to be avoided. Further, by artificially making the
make a simple incision, but cut it out in a anterior side of the middle hepatic vein bulge, the
circle. outflow of the right hepatic vein becomes
6. Using the inner thread of a 6-0 prolene enlarged, thus reducing the risk of outflow
double-­arm suture that has been previously obstruction that can occur as the liver regenerates
hung, pass the needle from the inside to the and rotates [7].
outside of the vessel graft and tie it. At this time, the anterior side of the right
7. Using the thread on the far side from the hepatic vein and the posterior side of the recon-
operator, suture in an over-and-over manner structed middle vein are sutured very close to
while moving toward the operator. During each other to prevent loosening, while the ante-
this process, be careful not to tear the blood rior side of the reconstructed middle hepatic vein
vessel or narrow the lumen by pulling the is 1.5–2 times wider than the back, making it
thread too hard. swell naturally due to the pressure of the vena
8. When approaching the other end, the last cava after reperfusion. This can have the effect of
stitch needs to be placed very close to the widening the lumen of the entire anastomosis
originally hung thread, and then a knot must (see Video 23.1).
be made outside the lumen.
9. Turning over the vessel graft in the opposite
direction, the anastomosis line on the oppo- 23.7 Reconstructed Middle
site side should be placed in front. Hepatic Vein after
10. Check the anastomosis you just made from Reperfusion
the inside.
11. After repeating the process in (6–8), cut the 1. After the reconstruction of the middle hepatic
thread. Be careful not to accidentally include vein using a cryopreserved iliac vein, the
the other side in this process. If there is any vascular graft was anastomosed to the con-
difficulty stemming from the narrow lumen, fluence of the middle and left hepatic vein
placing a dilator in the vessel graft helps pre- (Fig. 23.1).
vent mistakes.
12. Repeat steps (4) to (11) while matching the
direction and distance to the next tributary to
be anastomosed.

23.6 In the Case of Anastomosis

of Right Hepatic Vein
and Reconstructed Middle
Hepatic Vein as a Single
Orifice

If the right hepatic vein and the reconstructed

middle hepatic vein are made into one opening, Fig. 23.1 Reconstruction of the middle hepatic vein and
the bench surgery time is longer, but all the veins anastomosis to the recipient’s middle-left hepatic vein
can be anastomosed at once, thereby avoiding confluence using a cryopreserved iliac vein. Care should
be taken during anastomosis to ensure that the recon-
congestion in the right anterior section from structed middle hepatic vein is not distorted when blood
immediately after reperfusion to until the end of flow is resumed
134 D.-S. Kim

2. Outcome after anastomosis of the middle and References

right hepatic vein of the graft as a single
orifice using the cryopreserved iliac vein
­ 1. Lee S, Park K, Hwang S, Lee Y, Choi D, Kim K, et al.
(Fig. 23.2). Congestion of right liver graft in living donor liver
transplantation. Transplantation. 2001;71(6):812–4.
3. Anastomosis after reconstruction of the mid- 2. Chen HL, Tsang LL, Concejero AM, Huang TL, Chen
dle hepatic vein using PTFE (Fig. 23.3). TY, Ou HY, et al. Segmental regeneration in right-lobe
liver grafts in adult living donor liver transplant. Clin
Transpl. 2012;26(5):694–8.
3. Hwang S, Lee SG, Park KM, Kim KH, Ahn CS, Lee
YJ, et al. Hepatic venous congestion in living donor
liver transplantation: preoperative quantitative predic-
tion and follow-up using computed tomography. Liver
Transpl. 2004;10(6):763–70.
4. Hwang S, Lee SG, Ahn CS, Park KM, Kim KH, Moon
DB, et al. Cryopreserved iliac artery is indispensable
interposition graft material for middle hepatic vein
reconstruction of right liver grafts. Liver Transpl.
2005;11(6):644–9.
5. Hwang S, Jung DH, Ha TY, Ahn CS, Moon DB, Kim
KH, et al. Usability of ringed polytetrafluoroethylene
grafts for middle hepatic vein reconstruction dur-
ing living donor liver transplantation. Liver Transpl.
Fig. 23.2 Using a cryopreserved iliac vein, the opening 2012;18(8):955–65.
of the middle and right hepatic veins is made into a single 6. Cattral MS, Greig PD, Muradali D, Grant
orifice, while the anterior wall is designed to be large and D. Reconstruction of middle hepatic vein of a living-­
connected to the vena cava (see Video 23.1) donor right lobe liver graft with recipient left portal
vein. Transplantation. 2001;71(12):1864–6.
7. Sugawara Y, Makuuchi M, Akamatsu N, Kishi Y,
Niiya T, Kaneko J, et al. Refinement of venous
reconstruction using cryopreserved veins in right
liver grafts. Liver Transpl. 2004;10(4):541–7.

Fig. 23.3 Reconstruction of the middle hepatic vein

using an artificial graft
 Recipient Total Hepatectomy
24
Kwang-Woong Lee and Jaehong Jeong

Abstract
24.1 Introduction
Recipient total hepatectomy is an important
step for a successful liver transplantation. Recipient total hepatectomy is the process of
Specifically, in order to reduce biliary compli- removing the existing diseased liver for liver
cations, precise anatomical knowledge and transplantation (LT), and it requires rapid and
delicate surgical skills are required when han- accurate surgery, as there are many collateral ves-
dling the hepatic hilum. Further, in living sels and a major bleeding tendency due to cirrho-
donor liver transplantation, various approaches sis, along with sufficient anatomical knowledge
are required depending on the situation of the for successful vascular and biliary reconstruction
donor surgery and the quality of the graft. of the graft. In the case of living donor LT in par-
Therefore, various techniques should be ticular, when the hilar structures are dissected,
applied depending on the specific situation of they should be peeled to as long a length as pos-
the donor and the recipient. sible to obtain a bile duct, a hepatic artery, and a
portal vein of sufficient lengths. It is also very
Keywords important to avoid injury to the vessels supplied
to the biliary tract during biliary dissection. The
Liver transplantation · Recipient hepatectomy incidence of biliary complications after living
Benign biliary stricture · High hilar dissection donor LT has been reported to range from 8.4%
Portal vein thrombosis to as much as 35.8% [1]. In an effort to narrow
this wide range, a “High Hilar Dissection (HHD)”
was introduced in which, rather than dissecting
the structures of the hepatic hilum separately to
supply sufficient blood flow to the bile duct, the
Supplementary Information The online version con- hepatic hilum was cut all at once at the intrahe-
tains supplementary material available at https://doi.
org/10.1007/978-­981-­16-­1996-­0_24. patic level [2]. In this chapter, we will introduce
some techniques while ultimately focusing on the
process of dissecting hepatic hilum.
K.-W. Lee (*)
Department of Surgery, College of Medicine, Seoul
National University, Seoul, South Korea
J. Jeong
Soon Chun Hyang University Hospital,
Bucheon, South Korea

© Springer Nature Singapore Pte Ltd. 2023 135

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_24
136 K.-W. Lee and J. Jeong

24.2 Surgical Method 24.3 Handling of the Hepatic

Hilum
24.2.1 Incision
24.3.1 Classical Hilar Dissection
In general, the combination of a sub-costal inci- Technique
sion with a central upper incision is widely
used to secure the field of view, and even an Since vessels and bile duct of sufficient length are
inverted L-shaped incision may ensure a suffi- required for successful anastomosis of the graft, it
cient field of view. Severe cirrhosis may occa- is important to dissect each structure as long as
sionally cause severe bleeding during the skin possible. In particular, during biliary dissection, it
incision due to the development of collateral is very important to prevent damage to the blood
vessels, and caution is required during this inci- vessels supplied to the bile duct to reduce the bili-
sion. If the ligament teres is reopened, the por- ary complications, and it is also important to
tal pressure will increase when it is ligated secure a sufficient length to avoid tension during
during the incision, so care should be taken to biliary anastomosis. First, the hepatoduodenal lig-
avoid injuring it. ament is palpated to check the location of the
hepatic artery, after which the left side of the hepa-
toduodenal ligament is dissected to expose the
24.2.2 Mobilization of the Liver proper and left hepatic arteries. The proper hepatic
artery is completely peeled off, then encircled with
After the three hepatic vein inlets are sufficiently a vessel loop. Next, the origin of the right hepatic
dissected, mobilization of the left liver is per- artery is identified, the right hepatic artery is encir-
formed first. The left coronary and triangular cled with a vessel loop, and then the left and right
ligament are cut while pulling down the left hepatic arteries are dissected to a sufficient length.
liver. At this time, the left triangular ligament During this process, excessive pulling of the arter-
should be ligated. Next, the lesser omentum is ies should be avoided as it may increase the risk of
incised and the left liver is fully mobilized. Then, arterial thrombosis due to intimal injury. As the
the right coronary and triangular ligament are right hepatic artery is dissected, the portal vein is
cut while pulling down the right liver, and the exposed. Next, the portal vein is carefully dis-
hepatorenal ligament is cut afterward. At this sected along the portal wall and encircled with a
point, the bare area is dissected to expose the vessel loop. The bile duct is also sufficiently dis-
right side of the inferior vena cava. The short sected and encircled with a vessel loop. Then, each
hepatic vein between the inferior vena cava and structure is dissected to the liver as much as pos-
the liver is sequentially ligated and cut from cau- sible to facilitate anastomosis (Fig. 24.1).
dal to cranial, and from right to left. In this pro-
cess, it is not necessary to forcibly treat the short
hepatic veins located on the left side of the infe-
rior vena cava, and it is safe to treat them after
cutting the right hepatic vein, which provides
sufficient vision. Finally, when the middle and
left hepatic veins are cut after the liver is com-
pletely separated from the inferior vena cava, the
recipient total hepatectomy is considered to be
complete.

Fig. 24.1 Classical hilar dissection

24 Recipient Total Hepatectomy 137

24.3.2 High Hilar Dissection that it can cause severe portal hypertension,
Technique (HHD) which blocks the whole portal flow, in turn lead-
ing to intestinal congestion, metabolic derange-
Without individually dissecting the hepatic ment, or bleeding. In particular, in the case of
hilum, the entire hepatoduodenal ligament is poorly developed collateral vessels, the degree of
blocked with a sufficiently large vascular clamp, portal hypertension is more severe, and it may be
then the hilar plate is dissected to cut both glis- impossible to close the abdomen. To overcome
sonean pedicles over the second-order level. these shortcomings, a method of performing
When clamping the entire hepatoduodenal liga- HHD while maintaining portal flow was intro-
ment, care should be taken to avoid damage to the duced by Soejima et al. [3]. This is a method of
hepatic artery, and it should be clamped cephalad sufficiently dissecting only the portal vein while
as much as possible. The greatest advantage of leaving the bile duct and hepatic artery intact in
HHD is that it can secure a healthy bile duct in the handling of hepatic hilum, and it is important
which blood vessels are not damaged with suffi- to dissect along the portal vein wall. If both portal
cient length, which is beneficial during bile duct veins are sufficiently detached from the sur-
anastomosis (Fig. 24.2). In addition, since the rounding tissues, the bile duct and hepatic artery
portal vein can be obtained at the level of the sec- can be cut at the highest possible level. Since
ond branch, when the donor’s portal vein has two blood flow through both portal veins is wholly
separate openings in the living donor LT, the preserved, it is possible to flexibly respond to
recipient’s portal vein can be used as a Y-graft. various situations that can arise during the donor
This makes it possible to overcome the twisting surgery.
phenomenon in portal vein anastomosis.
24.3.3.2 Left Flow Preserving HHD
Left flow preserving HHD is a procedure that
24.3.3 Modified High Hilar only takes advantage of the above-described
Dissection Technique HHD and whole flow HHD techniques [4]. First,
only the right glissonean pedicle is clamped, then
24.3.3.1 Whole Flow Preserving HHD cut over the second-order level (Fig. 24.3). The
Depending on the circumstances, donor surgery main advantage of this technique is that it can
may be delayed. In this case, the application of secure a healthy biliary tract of a similar enough
HHD is limited. The biggest drawback of HHD is length to that of HHD, with another advantage

a b

Fig. 24.2 High hilar dissection. (a) Glissonean pedicles at the second order. (b) Complete dissection of each structure
after HHD
138 K.-W. Lee and J. Jeong

24.4 Portal Vein Thrombectomy

Portal vein thrombus is often found in patients

with advanced liver cirrhosis, and short segmen-
tal thrombus can be easily removed through the
careful eversion of the portal vein. It is not neces-
sary to completely remove the thrombus, and
careful manipulation is required as the weakened
portal vein wall may tear. Occasionally, portal
vein thrombosis may develop to the superior
mesenteric vein, in which case, after opening the
lesser sac by incising the greater omentum, dis-
secting between the lower border of the pancreas
and the mesentery of transverse colon can lead to
Fig. 24.3 Left flow preserving HHD
exposure of the superior mesenteric vein. If the
dissecting of the superior mesenteric vein is suf-
ficient, the superior mesenteric vein is then encir-
cled with a vessel loop. Finally, venotomy is
performed to carefully remove the thrombus.

24.5 Coping with and Prevention

of Bleeding during Surgery

As mentioned above, since most cases are accom-

panied by cirrhosis, there is a tendency for the
recipients to bleed easily due to the development
of collateral vessels and coagulopathy. In some
cases, the inferior phrenic artery is exposed in the
right bare area. If hemostasis is performed with an
Fig. 24.4 Complete separation from inferior vena cava electric cauterizer in response to bleeding here,
with left flow preserving HHD delayed bleeding may occur, so it is safe to suture
ligation with 4-0 prolene. Massive bleeding may
being that it can cut the right hepatic vein, so it occur during the cutting of the short hepatic vein,
can safely handle the short hepatic vein located in which case, compulsorily attempting ligation
on the left side of the inferior vena cava with without sufficient visibility can cause more severe
excellent visibility (Fig. 24.4). In addition, since bleeding. Therefore, the safe approach is to first
the blood flow to the liver is maintained through press the bleeding site with a finger and block the
the left portal vein, the middle and left hepatic blood flow to the liver, then dissect the surround-
veins, it can flexibly cope with situations that ing area to secure space, and finally suture the
may arise during the donor surgery. bleeding site from the inferior vena cava.
24 Recipient Total Hepatectomy 139

24.6 Conclusion References

Recipient total hepatectomy is not simply a pro- 1. Chok KS, Lo CM. Systematic review and meta-­
analysis of studies of biliary reconstruction in adult
cedure for removing diseased liver, but it is a pre- living donor liver transplantation. ANZ J Surg.
liminary step toward transplanting a new liver, so 2017;87(3):121–5.
it must be flexibly performed according to the 2. Lee KW, Joh JW, Kim SJ, Choi SH, Heo JS, Lee HH,
specific situations of the donor and the recipient. et al. High hilar dissection: new technique to reduce
biliary complication in living donor liver transplanta-
The acceptable anhepatic time varies depending tion. Liver Transpl. 2004;10(9):1158–62.
on the degree of development of collateral ves- 3. Soejima Y, Fukuhara T, Morita K, Yoshizumi T,
sels and the delay in donor surgery, and the tech- Ikegami T, Yamashita Y, et al. A simple hilar dissec-
nique used to dissect the hepatic hilum may vary tion technique preserving maximum blood supply
to the bile duct in living donor liver transplantation.
depending on the condition of the bile duct and Transplantation. 2008;86(10):1468–9.
vessels of the donor, or its location if there is liver 4. Shehta A, Jeong J, Lee KW, Lee JM, Hong SK, Cho
cancer. Therefore, various techniques of the pro- JH, et al. A tailored strategy for recipient hepatec-
cedure should be applied depending on the situa- tomy: left portal flow preserving high hilar dissection.
J Gastrointest Surg. 2019;23(12):2466.
tion, and proper communication with the donor
operator is essential.
 Reconstruction of Hepatic Vein
and Portal Vein 25
Deok-Bog Moon and Sung-Gyu Lee

Abstract Keywords

To ensure a successful liver transplantation Hepatic vein · Venoplasty · Portal vein

(LT), one must secure adequate hepatic arte- Anastomosis · Back-table operation · LDLT
rial and portal inflow, as well as good outflow
through the hepatic veins (HVs).
Wide HV outflow can be achieved through 25.1 Reconstruction
pertinent HV venoplasty of the liver graft at of Hepatic Vein
the back-table and of the recipient in vivo.
These procedures not only allow for a wide To ensure a successful liver transplantation (LT),
anastomotic opening of the HV to be made, one must secure adequate hepatic arterial and
but they also enable easy and safe HV anasto- portal inflow, as well as good outflow through the
mosis, even under a bad operative visual field. hepatic veins (HVs). Wide HV outflow can be
As a result, the technical complications of achieved by pertinent HV venoplasty of the liver
hepatic venous outflow can be minimized. graft at the back-table and of the recipient in vivo,
In the case of single graft LDLT, the recipi- then the congestion-induced dysfunction of the
ent’s right or left portal vein (PV) is not typi- implanted liver graft can be minimized [1].
cally used for PV reconstruction; instead,
bifurcation of the main PV is preferred to avoid
redundancy and stenosis. In the case of dual 25.1.1 Back-Table Procedures
graft LDLT, the long-length recipient’s right and
left PV should be kept intact during hilar dissec- 25.1.1.1 Modified Right Lobe Graft
tion, so they can be used for PV reconstruction Augmentation HV venoplasty should be per-
of both grafts. At this time, we should try to fur- formed when the right hepatic vein (RHV) is not
ther reduce the risk of PV twisting by maintain- large enough for a diameter exceeding 3–4 cm.
ing good alignment during anastomosis. While there are several types of RHV veno-
plasty, the most common type involves a longitu-
dinal incision of the inferior corner of RHV
D.-B. Moon · S.-G. Lee (*) including hepatic parenchyma, followed by aug-
Division of Hepatobiliary Surgery and Liver mentation patch venoplasty using the recipient’s
Transplantation, Department of Surgery, Asan
bisected great saphenous vein (GSV) after dila-
Medical Center, University of Ulsan College of
Medicine, Seoul, South Korea tation with hydrostatic pressure; this is also the
e-mail: [email protected]; [email protected] most reliable method when no homologous vas-

© Springer Nature Singapore Pte Ltd. 2023 141

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_25
142 D.-B. Moon and S.-G. Lee

Fig. 25.1 Venoplasty of right hepatic vein (RHV) at the venoplasty was performed using a bisected great saphe-
back-table. First, a longitudinal incision was made into nous vein (GSV) patch. RHV right hepatic vein, GSV great
the parenchyma at the inferior corner, then augmentation saphenous vein

cular graft can be obtained from the deceased of RHV using a vascular-patch fence can help us
organ donor [2, 3]. Hence, we can make a more perform wide and easy RHV anastomosis
than 4 cm-sized large RHV at the back-table and (Fig. 25.2).
minimize the risk of HV stenosis or kinking, When the modified right lobe graft has two or
which can occur as a result of the post-trans- more short HVs that are larger than 5 mm in
plant-enlarged liver graft related mostly to diameter, we should reconstruct them in the same
regeneration or, less commonly, acute rejection way as the sizable middle HV branches [4, 5]. In
(Fig. 25.1). The recipient’s re-canalized paraum- the case of a single short HV, the previously
bilical vein and cadaveric iliac vein can be used described augmentation patch venoplasty is
as alternative vascular patches for HV veno- required to avoid venous outflow disturbance.
plasty, and cadaveric arteries or PTFE artificial Compared to the right HV, we need to be more
vascular grafts are used in rare situations as well. cautious about the condition of the vascular wall
The operative techniques do not differ much in regard to whether or not it has a weak portion
among the various types of vascular patches, and and too short of a stump length; when it does have
in this study, we primarily describe the method both of these characteristics, an incision including
of venoplasty using bisected GSV. the hepatic parenchyma should be made along the
When procuring the liver graft laparoscopi- weak portion, and patch venoplasty or vascular
cally, we often encounter a liver graft with too fence should be performed to make a short HV
short of an HV stump from the parenchymal sur- with a wide opening and adequate stump length.
face, and its anastomosis cannot be performed In the case of two or more short HVs, separate
safely without venoplasty at the back-table. In anastomosis is sometimes performed when two
this inconvenient situation, using a combination short HVs are wide apart and have sufficiently
of previously described augmentation venoplasty large diameters. However, technical errors may
and the additional neo-vascular stump formation arise when there is a space discrepancy between
25 Reconstruction of Hepatic Vein and Portal Vein 143

Fig. 25.2 Venoplasty of RHV with a short stump or even GSV. Hence, the newly formed RHV has a wide diameter
no stump at the back-table. First, a longitudinal incision and sufficient stump length. RHV right hepatic vein, GSV
was made into the parenchyma at the inferior corner, then great saphenous vein
a neo-vascular stump was made with fencing of bisected

the recipient’s right upper quadrant after total 25.1.1.2 Extended Right Lobe Graft
hepatectomy and the donor’s liver graft, and sub- Back-table procedures for both right and mid-
sequent outflow disturbances occur more fre- dle HVs are necessary to secure good venous
quently when the regeneration of the liver graft outflows. When separate anastomosis of RHV
displaces the inferior vena cava and aggravates and MHV is prepared, the procedures are
kinking of the short HVs. To avoid those prob- almost the same for the modified right lobe
lems, one solution is to make a wide common HV graft, and they refer to a previous description
opening from the multiple short HVs at the back-­ [4]. The only precaution that must be taken is to
table through the combination of augmentation ensure that the MHV stump has an adequate
patch venoplasty and vascular fencing [6]. This length, which can be accomplished using an
procedure can help us perform easy and simple interposition vascular graft for tension-free and
anastomosis in the recipient while reducing the easy anastomosis with the recipient’s common
risk of venous outflow disturbance (Fig. 25.3). trunk of middle and left HV.
144 D.-B. Moon and S.-G. Lee

Fig. 25.3 Venoplasty of multiple short hepatic veins bridging patch of bisected GSV, and finally, a wide single
(SHVs) at the back-table. First, longitudinal incisions are SHV opening is made by fencing of bisected GSV. SHV
made between SHVs in the same manner as the veno- short hepatic vein, RHV right hepatic vein, GSV great
plasty of RHV. Second, the SHVs are connected by a saphenous vein

When single anastomosis of RHV and MHV is and leave a big segment 4 HV in the donor side,
prepared using an all-in-one method, we should which drains into the MHV trunk nearby, the RHV
make a single wide common HV opening at the and MHV are a wide distance apart, and making a
back-table according to the following steps [7]: common opening without a bridging vascular patch
First, bridging patch venoplasty should be per- is difficult and can lead to a disastrous situation,
formed between RHV and MHV, after which a vas- such as tearing of the vascular wall and prevention
cular fence using bisected GSV or other vascular of anastomosis related to the excessive tension dur-
patch should be attached to the common opening, ing implantation (Fig. 25.5).
except for the posterior wall of RHV, to lengthen
the anterior wall of the opening. This not only 25.1.1.3 Left Lobe Graft
allows us to perform easy and safe anastomosis by A left lobe graft may have a higher chance of
decreasing the tension of anastomosis, but also venous outflow disturbance when used for a sin-
reduces the risk of outflow obstruction by forming gle or dual graft living donor liver transplantation
a big pouch toward the superior, inferior, and ante- (LDLT), because such situations offer an inade-
rior sides of anastomosis (Fig. 25.4). The Hong quate atmosphere to stably support the liver graft.
Kong group does not perform bridging venoplasty Hence, HV augmentation venoplasty at the back-­
and vascular fencing of the anterior wall, but only table is essential to reduce the complication of
makes a triangular-shaped common opening venous outflow.
between RHV and MHV with approximation cor- In cases of pediatric LDLT, HV of the left lobe
ner sutures at the superior and inferior sides along graft from an adult living donor is typically large
with an additional transverse incision including the enough for the recipient’s HV, and augmentation
hepatic parenchyma followed by continuous venoplasty at the back-table is not usually
approximation sutures [8]. At a basic level, we required. However, a single large common HV
share the creation of a single common opening opening should be made by dividing the vascular
between RHV and MHV with that method. septum between RHV, MHV, and left hepatic
However, when we procure the extended RL graft vein (LHV) in the pediatric recipient.
25 Reconstruction of Hepatic Vein and Portal Vein 145

Fig. 25.4 Venoplasty between RHV and middle hepatic the inferior corner of the RHV is made. Second, a single
vein (MHV) of extended right lobe graft at the back-table. wide common opening of RHV and MHV is made by
First, a bridging patch with bisected GSV is placed fencing of bisected GSV. RHV right hepatic vein, MHV
between RHV and MHV, and a longitudinal incision of middle hepatic vein, GSV great saphenous vein

In the case of an adult single left lobe graft We may incise the corner of the MHV side or
LDLT, it is very important to perform wide HV both the MHV and LHV sides, then perform aug-
anastomosis to decrease the post-transplant mentation venoplasty. When the recipient’s com-
hepatic venous outflow disturbances. In the mon HV opening is too large compared to the HV
recipient’s side, we should use the common HV of the left lobe graft, or when the HV stump of
opening after dividing the septum between RHV, the left lobe graft is too short for comfortable
MHV, and LHV. Correspondingly, the HV of the anastomosis, we prefer to additionally perform
left lobe graft should be enlarged to match the combined fencing to the HV of the left lobe graft,
recipient’s large common HV opening through and a large HV opening with an HV stump of a
HV augmentation venoplasty at the back-table sufficient length can be made for wide and easy
using bisected GSV or other vascular patches [1]. anastomosis (Fig. 25.6).
146 D.-B. Moon and S.-G. Lee

Fig. 25.5 Venoplasty of extended right lobe graft at the shaped common opening is made using continuous
back-table by the Hong Kong group. First, direct approxi- sutures of the approximation line, but it lacks an adequate
mation sutures are placed without a vascular patch stump length for a common hepatic vein opening, except
between RHV and MHV, then a transverse incision for the posterior wall of RHV. RHV right hepatic vein,
including hepatic parenchyma is performed at the mid-­ MHV middle hepatic vein
point of the approximation line. Finally, a triangular-­

Fig. 25.6 Venoplasty of middle and left hepatic veins GSV is useful for making a wide common HV opening
(LHV) common opening of left lobe graft at the back-­ with an adequate stump length when the stumps of HV are
table. Augmentation venoplasty can either be conducted too short and/or multiple HV openings come out. MHV
only at the MHV side or at both the MHV and LHV sides. middle hepatic vein, LHV left hepatic vein, HV hepatic
Additional fence to the hepatic vein (HV) using bisected vein, GSV great saphenous vein
25 Reconstruction of Hepatic Vein and Portal Vein 147

In the case of dual graft LDLT using two left interposing vascular grafts of more than 5 mm-­
lobes [9, 10], we perform augmentation HV sized MHV branches should all be reconstructed
venoplasty to both left lobe grafts, and the trans- in the recipient. Basically, we should make the
verse diameter of the middle and left HV com- HV openings in the recipient wider than those of
mon opening should be made to have a length the donor’s liver graft. In the case of RHV, a lon-
exceeding 3 cm by using a vascular patch or gitudinal incision is commonly made in the infe-
fencing [1]. rior corner RHV including the IVC wall to adjust
the size of the donor’s RHV [2] (Fig. 25.7). When
the right lobe graft is larger than the recipient’s
25.1.2 Recipient Operation right upper quadrant space after total ­hepatectomy,
or when the locations of HV inflow between
To achieve good hepatic venous outflow, we need RHV of the liver graft and the recipient’s RHV
to perform pertinent venoplasty to each of the are different than the cross-section line of the
recipient’s RHV, middle and left HV common recipient’s IVC, a longitudinal incision of the
opening, and inferior vena cava (IVC), in the inferior corner of the recipient’s RHV is often not
same way as the back-table operation of the enough by itself to secure good RHV outflow. As
donor liver graft. These procedures make it pos- an alternative measure, the combination of a
sible to not only make a wide anastomotic open- transverse incision of the anterior wall of RHV
ing of the HV, but also perform easy and safe HV and a longitudinal incision of the inferior corner
anastomosis, even under a bad operative visual of RHV including the IVC wall allows us to con-
field. As a result, we can minimize the technical vert the elliptical RHV opening to an oval shape,
complications of hepatic venous outflow [1]. and subsequently reduce the risk of outflow dis-
turbance of RHV. However, this method is not
25.1.2.1 Modified Right Lobe Graft safe, because there is a risk of a disastrous event
Upon completion of the back-table operation, the related to the excessive tension during RHV
HVs of the modified right lobe graft including anastomosis as well as the tearing of its vascular
RHV, more than 5 mm-sized short HVs, and wall. Patch venoplasty including vascular fence

Fig. 25.7 Venoplasty of recipient’s RHV before engraftment. Longitudinal incision only including the inferior vena
cava (IVC) wall is performed at the inferior corner of RHV. RHV right hepatic vein, IVC inferior vena cava
148 D.-B. Moon and S.-G. Lee

Fig. 25.8 Venoplasty of recipient’s RHV using bisected new RHV opening with an adequate stump length using
GSV-patch before engraftment. First, we make a large HV bisected GSV-patch venoplasty to the inferior corner of
opening with a longitudinal incision including the IVC the incised RHV. RHV right hepatic vein, GSV great
wall at the inferior corner of RHV, and then we make a saphenous vein, HV hepatic vein, IVC inferior vena cava

with bisected GSV or other vascular materials the recipient’s middle and left HV common open-
might help substantially mitigate those risks. As a ing [4]. For a recipient who has previously had
result, the newly made large recipient’s RHV hepatocellular carcinoma, intrahepatic duct
opening has an adequate stump length with a stones, or other related conditions, left-sided hep-
healthy vascular wall at the lower half of the atectomy is often impracticable, because LHV is
anterior wall and the lower 1/2 or 1/3 of the pos- absent and because MHV can frequently not be
terior wall, and we can therefore easily and safely accurately obtained. Under those conditions, the
perform wide RHV anastomosis (Fig. 25.8). MHV interposition graft can be anastomosed with
Short HV anastomosis should be performed at the anterolateral wall of the recipient’s
the corresponding location of the recipient’s IVC IVC. However, we prefer single HV anastomosis
after a larger incision in the IVC wall than the to two separate anastomoses such as extended
graft of the short HV. The IVC wall should be right lobe graft. The RHV and MHV interposition
excised to make it an oval shape rather than an graft should be made into a large common HV
elliptical shape to avoid venous outflow distur- opening through quilt venoplasty, then anasto-
bance. Under a poor operation field, it is difficult mosed with the enlarged recipient’s RHV through
to match the short HV location between the ample incisions into the IVC wall both longitudi-
graft’s short HV and the recipient’s IVC, and we nally and transversely. At this time, we should
should demarcate its corresponding site at the perform fencing with bisected GSV to the anterior
recipient IVC before engraftment in consider- wall of the recipient’s newly made wide RHV
ation of both the longitudinal and transverse loca- opening, and this procedure can help us perform
tions of the graft short HV. Measuring the HV anastomosis safely without the risk of tearing
distance between the graft’s RHV and short HV from the excessive tension that occurs during
as well as specifying the transverse location of anastomosis (Fig. 25.9). In addition, total clamp-
the graft’s IVC groove might help the anastomo- ing of the recipient’s IVC, including RHV longi-
sis at the appropriate site. tudinally or transversely, along with the
The MHV interposition graft draining segment application of veno-venous bypass, can often be
5 and 8 hepatic veins are typically anastomosed to beneficial for the operative procedure.
25 Reconstruction of Hepatic Vein and Portal Vein 149

Fig. 25.9 Venoplasty of recipient’s RHV using bisected shaped wide HV opening. Then, additional bisected GSV-­
GSV-patch after additional transverse incision. First, we patch venoplasty can give the new large RHV an adequate
perform both longitudinal and transverse incisions includ- stump length. RHV right hepatic vein, GSV great saphe-
ing the IVC wall at the inferior corner and the mid-portion nous vein, IVC inferior vena cava, HV hepatic vein
of the anterior wall of RHV, respectively, to make an oval-­

25.1.2.2 Extended Right Lobe Graft MHV. When the liver graft is too big for the
In the case of separate anastomoses of RHV and recipient’s right upper quadrant space after total
MHV, the method of HV anastomosis is the same hepatectomy, the transverse incision should be
as that for the modified right lobe graft [3]. extended into the recipient’s LHV for the graft’s
In the case of single anastomosis, after mak- MHV to maintain its course more naturally.
ing a common HV opening between RHV and Bisected GSV fencing to the newly made large
MHV of the liver graft at the back-table, we HV opening in the recipient can avoid disastrous
should clamp the recipient’s IVC longitudinally, events resulting from the tearing of its anastomo-
including RHV and MHV, or clamp the recipi- sis related to the undue tension during anastomo-
ent’s both supra- and infrahepatic IVC, including sis, and the dome-shape contour of HV
all three HVs under veno-venous bypass. In con- anastomosis after perfusion can secure good HV
sideration of the longitudinal and transverse outflow regardless of any post-transplant mor-
diameters of the graft’s common HV opening, we phologic changes related to regeneration of the
can incise the recipient’s RHV into the IVC wall liver graft or its swelling due to acute rejection
longitudinally and transversely, and the Hong (Fig. 25.10).
Kong group routinely makes a triangular-shaped
HV opening without patch plasty after excision 25.1.2.3 Left Lobe Graft
of the IVC wall [8]. To make an anastomosis Similar to the right lobe graft positioning at the
while maintaining the natural course of the graft’s right upper quadrant space orthotopically, we
MHV, a transverse incision of the recipient’s implant the left lobe graft orthotopically, but it is
RHV anterior wall should be made into typically leaning toward the right upper quadrant
150 D.-B. Moon and S.-G. Lee

Fig. 25.10 Venoplasty of recipient’s HVs before engraft- except for the posterior wall of RHV is made to avoid
ment of extended right lobe graft. First, a new large com- excessive tension during anastomosis and to create a
mon hepatic opening is made by a transverse incision dome-shape wide HV outflow. HV hepatic vein, RHV
from the recipient’s RHV to the middle and left HV com- right hepatic vein, GSV great saphenous vein
mon trunk. Then, vascular fence using bisected GSV

space due to its empty space. This may result in ing, and it might be necessary to perform a size
twisting of HV anastomosis, and severe outflow reduction venoplasty of the recipient’s RHV-­
disturbance can occur. MHV-­ LHV common opening to ensure size
As a countermeasure, we should make a large matching and safe anastomosis; this can be
common HV opening including all three major accomplished by suturing the divided septal wall
HVs of the recipient by dividing the septum between RHV and MHV in both the anterior and
between RHV, MHV, and LHV under supra- and posterior sides, which can also form an HV stump
infrahepatic IVC clamping with veno-venous with an adequate length.
bypass, then performing anastomosis with the When we performed an augmentation HV
enlarged common HV opening of the left lobe venoplasty using both a vascular patch and fenc-
graft with bisected GSV patch venoplasty or ing in the left lobe graft at the back-table, its
fencing at the back-table. This kind of maximally transverse diameter was already sufficiently
enlarged HV anastomosis can minimize the enlarged for direct anastomosis with the recipi-
twisting effect depending on the position change ent’s RHV-MHV-LHV common opening, and
of the left lobe graft. The transverse diameter of there was no need to perform an additional proce-
the recipient’s RHV-MHV-LHV common open- dure on the recipient side.
ing is large, at around 4–5 cm in length, but the As an additional measure to reduce HV out-
transverse diameter of the graft’s MHV-LHV flow disturbance, we placed a tissue-expander in
common opening after patch venoplasty alone is the right upper quadrant space to support the left
often not sufficiently large to anastomose with lobe graft. This was intended to prevent excessive
the recipient’s RHV-MHV-LHV common open- tilting of the left lobe graft toward the right side.
25 Reconstruction of Hepatic Vein and Portal Vein 151

Fig. 25.11 Tissue-expander into the right upper quadrant space to support the left lobe, which prevents excessive tilt-
ing of the left lobe graft toward the right side and helps maintain good HV outflow

In addition, to maintain good HV outflow, we through augmentation venoplasty at the back-­

began to deflate the tissue-expander step-by-step table [10]. During long anhepatic phase, which
after 1 week, but retained it for 2–3 weeks until completely blocks the portal and systemic venous
HV anastomosis could not be deformed any fur- return, veno-venous bypass is necessary to main-
ther with the aid of graft regeneration and the for- tain stable vital signs and to prevent mesenteric
mation of perihepatic adhesion (Fig. 25.11). congestion. The absence of veno-venous bypass
can infrequently result in postoperative severe or
25.1.2.4 Dual Liver Graft even necrotizing pancreatitis related to mesen-
Compared to single graft LDLT, dual graft LDLT teric congestion; in which case one should not
requires a longer operation time, particularly in hesitate to apply veno-venous bypass when there
anhepatic phase. Under supra- and infrahepatic is complete blockage of portosystemic venous
clamping, we should perform augmentation return.
venoplasty at both RHV and MHV-LHV of the
recipient after transverse and/or longitudinal Two Left-Sided Liver Grafts
incision toward the IVC wall to accommodate the In consideration of a good operation field, we
already enlarged HV openings of the grafts should start HV anastomosis from the right-sided
152 D.-B. Moon and S.-G. Lee

graft positioning in a 180° counterclockwise the corner of the MHV side, after which augmen-
rotation, then apply a 90°clockwise rotation. In tation venoplasty using bisected GSV patch
the early period, interposition of the cadaveric should be performed for size-matching with the
iliac vein between the recipient’s RHV and HV enlarged HV of the left-sided graft with a trans-
of the right-sided liver graft was performed to verse diameter of more than 3 cm. When the
decrease the tension of HV anastomosis and to stump length of the MHV-LHV common opening
facilitate right portal vein (PV) and BD anasto- is too short and the HV anastomosis is antici-
mosis [9, 11]. We no longer use interposition pated to be difficult, we should perform vascular
grafts because they were often the cause of HV fencing including patch venoplasty to the recipi-
outflow disturbance due to redundancy, and they ent’s enlarged MHV-LHV opening to make the
did not actually affect the right PV and BD anas- HV stump have an adequate length (Fig. 25.12).
tomosis [10]. This procedure guarantees that the anastomosis
The recipient’s RHV is incised longitudinally of HV will proceed safely without tearing under
at the inferior corner for size-matching with the a poor operation field and even in the presence of
enlarged HV of the right-sided graft through aug- extreme tension during anastomosis.
mentation venoplasty. If extensive tension of the
HV reconstruction is expected from the exces- Right- and Left-Sided Liver Grafts
sively large size of the recipient’s right upper Both liver grafts are orthotopically positioned,
quadrant space, additional bisected GSV fencing and the same reconstruction methods described
to the lower half of the enlarged recipient’s RHV previously are respectively used for the right-
might be beneficial to decrease the tension of HV and left-sided liver grafts. We begin by perform-
anastomosis. ing reconstruction of HVs including RHV, SHV,
The recipient’s MHV-LHV common opening and MHV interposition grafts of the right-sided
typically needs to be incised into the IVC wall at graft, then proceed with anastomosis HV of the

Fig. 25.12 Venoplasty of recipient’s HVs before implan- cular patch venoplasty and/or fencing are performed at
tation of dual-graft using two left-sided grafts. Incisions both HVs using bisected GSV. HV hepatic vein, RHV right
are made at the inferior corner of RHV and the right cor- hepatic vein, GSV great saphenous vein
ner of the middle and left HV common trunk. Then, vas-
25 Reconstruction of Hepatic Vein and Portal Vein 153

Fig. 25.13 Venoplasty of recipient’s HVs before implan- make a transverse incision at the right-side corner to make
tation of dual-graft using right- and left-sided grafts. In wide HV openings. Then, vascular patch venoplasty and/
RHV, we make longitudinal and transverse incisions at the or fencing are performed at both HVs using bisected GSV.
inferior corner and the mid-point of anterior wall, respec- HV hepatic vein, RHV right hepatic vein, GSV great
tively. In the middle and left HV common trunk, we also saphenous vein

left-­
sided graft to the recipient’s MHV-LHV redundancy and stenosis. In the case of dual graft
common trunk. The important difference in LDLT, we should keep the recipient’s right and
reconstruction compared to the two left-sided left PV intact during hilar dissection and use
liver grafts lies in how the MHV interposition them for the PV reconstruction of both grafts. To
graft is reconstructed, because the MHV interpo- reduce the risk of PV twisting, we perform
sition graft cannot be anastomosed to the recipi- ­anastomosis of each of the medial and lateral cor-
ent’s MHV-LHV common trunk. It can be ners of the recipient’s right and left PVs with the
reconstructed to the anterior wall of the IVC medial and left corners of each of the PVs of both
after a longitudinal incision or excision, but we grafts when based on the recipient’s coronal
currently prefer to perform single anastomosis plane.
between the large common HV opening of the PV of the procured partial liver graft often
right-side graft through quilt venoplasty at the comes out with a paper-thin wall and/or too short
back-table and by enlarging the recipient’s RHV of a stump, and the recipient’s PV is often exces-
through ample incision into the IVC wall longi- sively enlarged and thick-walled under long-­
tudinally and transversely (Fig. 25.13). standing portal hypertension. The severe
discrepancy between the graft’s and recipient’s
PV during anastomosis may cause embarrassing
25.2 Reconstruction of Portal Vein events such as tearing or technical difficulties.
For safe and easy PV anastomosis in those situa-
In the case of single graft LDLT, the recipient’s tions, we should perform PV re-enforcement by
right or left PV is not usually used for PV recon- placing bisected GSV over the weakened PV
struction, as main PV is preferred, to avoid wall of the graft and/or making a funnel-shaped
154 D.-B. Moon and S.-G. Lee

a b

Fig. 25.14 Management of the portal vein (PV) of the when the diameter of PV is too small for the recipient’s
liver graft at the back-table. (a) When the wall of the PV large PV, we need to make a funnel-shaped vascular fenc-
is paper-thin, we need to perform PV re-enforcement ing using bisected GSV to obtain a sufficiently wide open-
using bisected GSV to avoid tearing of the wall during ing that is thick-walled and that has an adequate stump
anastomosis. (b) When the stump of PV is too short, or length. PV portal vein, GSV great saphenous vein

vascular fencing of the graft PV to have a wide routes for lethal post-transplant portal flow steal
opening that is thick-walled and that has an ade- [12, 13]. By using IOP, we can perform not only
quate stump length at the back-table (Fig. 25.14). ballooning or stent placement to the residual PV
When PV thrombosis and/or stenosis are pres- thrombosis and/or stenosis, but also surgical
ent in the recipient, we should first try to perform interruption or embolization of the sizable porto-
thrombectomy while taking extreme caution to systemic collaterals.
keep the PV wall intact. However, when throm-
bectomy is not feasible for keeping the PV wall
intact, we prefer to leave it alone, then measure 25.2.1 Right Lobe Graft
the intraluminal diameter at the expected anasto-
motic site of the recipient’s PV. If the diameter is The donor’s first-order PV branches including
small, with a size of less than 1 cm, PV plasty right and left PV typically ramify from main PV,
should be performed using bisected GSV or other but the second-order PV branches in the right
vascular patches to enlarge the recipient’s PV lobe graft, including right anterior and posterior
diameter to avoid anastomotic stenosis [12] PV, often ramify directly from main PV without
(Fig. 25.15). common trunk of right PV, such as type 2 or 3
In contrast to pediatric LDLT, effective throm- PV variations. In the case of the procurement of
bectomy or plasty through the whole length of a right lobe graft in a donor with type 2 or 3 PV
PV in adult LDLT is often not possible, particu- variations, nostril-shaped or two separate PV
larly for intrapancreatic PV, due to periportal openings entering into each of the right anterior
inflammatory changes that occur under severe and posterior sectors come out. At the back-
portal hypertensive state. Hence, we should per- table, we can make a single PV opening by using
form intraoperative cine-portogram (IOP) after the recipient’s PV Y-graft, and safe and easy PV
engraftment to identify the residual PV thrombo- anastomosis is possible during implantation
sis and/or stenosis, along with co-existing sizable [14]. However, when we cannot obtain a healthy
portosystemic collaterals, which can be possible recipient’s PV Y-graft to pre-existing PV steno-
25 Reconstruction of Hepatic Vein and Portal Vein 155

a b

c d

Fig. 25.15 Management of PV obstruction or stenosis. hypertensive state. (d) PV anastomosis was performed
(a) The recipient had severe PV stenosis and a large coro- without stenosis at the anastomosis, but the residual steno-
nary vein as portosystemic collaterals. (b) Organized PV sis of intrapancreatic PV was relieved by intraoperative
thrombus was removed by eversion thrombectomy. (c) We PV stenting and interruption of coronary vein under the
performed PV plasty using bisected GSV because PV was guidance of intraoperative cine-portogram (IOP). PV por-
still stenotic even after thrombectomy, but intrapancreatic tal vein, GSV great saphenous vein, IOP intraoperative
PV was not amenable to PV plasty due to periportal cine-portogram
inflammatory changes occurring under severe portal
156 D.-B. Moon and S.-G. Lee

a b

Fig. 25.16 Management of multiple PV openings of the and we can thereby avoid kinking of the reconstructed PV
right lobe graft, such as type 2 or 3 PV, at the back-table. Y-graft. (b) When a healthy recipient’s PV Y-graft is not
(a) When nostril-shaped or two separate PV openings available due to pre-existing PV stenosis or thrombosis, a
come out, a PV single opening is made using the recipi- single PV opening with an adequate stump can be made
ent’s PV Y-graft. At the time of Y-graft anastomosis to the by bridging between the two PV openings of the liver
graft PVs, both medial sides should be everted as much as graft and then additional fencing using the recipient’s
possible, while both lateral sides should not be everted as bisected GSV patch or a fresh cadaveric iliac vein Y-graft.
much. Hence, the anastomotic openings are enlarged PV portal vein, GSV great saphenous vein
while the distance between PV bifurcation is minimized,

sis or thrombosis, we should make a single PV sutures are placed between the LPV of the graft
opening with the recipient’s bisected GSV bridge and the recipient’s MPV, we can perform PV
and fence, or a fresh cadaveric iliac vein Y-graft anastomosis without the risk of twisting of PV
[15] (Fig. 25.16). anastomosis. When the recipient has a small
anterior-to-posterior depth between the abdomi-
nal wall and the spine, the reconstructed PV of
25.2.2 Left Lobe Graft the left lobe graft might be compressed and
become stenotic in an orthotopic position. In that
The left PV of the graft is relatively small com- situation, we should place the left lobe graft in
pared to the right PV, and the chance of anasto- the right-side tilting position toward the spacious
motic stenosis of the PV is also high. Hence, right upper quadrant space to avoid PV compres-
performing PV anastomosis with closer sewing sion. However, we should also insert a tissue-­
and while providing growth factor at the time of expander into the right upper quadrant space to
completion is helpful for reducing the risk of support the left lobe graft and to avoid twisting of
anastomotic stenosis. The right and left corners the vascular structures including HV and PV,
of the PV stump of the graft can be decided by which might be related to excessive right-side
the transverse direction to the umbilical portion tilting of the left lobe graft.
of the left PV, and we can easily access them by
opening the tips of the Mixter clamp after hav-
ing inserted it into the umbilical portion of the 25.2.3 Dual Lobe Grafts
left PV.
In the recipient, the right and left corners of In the case of dual graft LDLT using both right
the main PV should be decided by the recipient’s and left lobe grafts, the methods of PV anastomo-
coronal plane. After the right and left corner sis are basically the same as those used in the PV
25 Reconstruction of Hepatic Vein and Portal Vein 157

reconstructions of the right and left lobe grafts, 4. Lee SG. Techniques of reconstruction of hepatic
respectively. In the recipient, each of the right veins in living-donor liver transplantation, especially
for right hepatic vein and major short hepatic veins
and left corners of the right and left PVs can be of right-lobe graft. J Hepato-Biliary-Pancreat Surg.
determined by the recipient’s coronal plane, simi- 2006;13(2):131–8.
lar to the single LDLT. Marking with a sterilized 5. Lee S, Park K, Hwang S, Lee Y, Choi D, Kim K, et al.
pen might be helpful to ensure that anastomosis Congestion of right liver graft in living donor liver
transplantation. Transplantation. 2001;71(6):812–4.
is performed correctly without twisting. In addi- 6. Hwang S, Lee SG, Park KM, Kim KH, Ahn CS,
tion, the length of each of the recipient’s right and Moon DB, et al. Quilt venoplasty using recipient
left PV to the anastomotic sites of each PV of the saphenous vein graft for reconstruction of multiple
liver graft should be short to avoid the presence short hepatic veins in right liver grafts. Liver Transpl.
2005;11(1):104–7.
of excessive tension during PV anastomosis. In 7. Hwang S, Lee SG, Ahn CS, Moon DB, Kim KH, Ha
the graft side, each of the right and left corners of TY, et al. Outflow vein reconstruction of extended
the right and left PV can be demarcated using the right lobe graft using quilt venoplasty technique.
same method used in each single graft LDLT. Liver Transpl. 2006;12(1):156–8.
8. Lo CM, Fan ST, Liu CL, Wong J. Hepatic venoplasty
In the case of dual graft LDLT using two left in living-donor liver transplantation using right lobe
lobe grafts, we should be particularly careful graft with middle hepatic vein. Transplantation.
when performing right PV anastomosis to the 2003;75(3):358–60.
right-sided graft, because the right-sided graft is 9. Lee S, Hwang S, Park K, Lee Y, Choi D, Ahn C, et al.
An adult-to-adult living donor liver transplant using
positioned based on a 180° counterclockwise dual left lobe grafts. Surgery. 2001;129(5):647–50.
rotation followed by a 90° clockwise rotation sta- 10. Song GW, Lee SG, Moon DB, Ahn CS, Hwang
tus. However, the determinations of the right and S, Kim KH, et al. Dual-graft adult living donor
left corners of the PV stump of the right-sided liver transplantation: an innovative surgical proce-
dure for live liver donor Pool expansion. Ann Surg.
graft (inverted left lobe graft) can be made using 2017;266(1):10–8.
the same method used for single left lobe graft 11. Lee SG, Hwang S, Park KM, Kim KH, Ahn CS, Lee
LDLT. Both corners of the PV stump of the YJ, et al. Seventeen adult-to-adult living donor liver
inverted left lobe graft can be determined by the transplantations using dual grafts. Transplant Proc.
2001;33(7–8):3461–3.
transverse direction to the umbilical portion of 12. Moon DB, Lee SG, Ahn CS, Hwang S, Kim KH, Ha
the left PV, and we can perform right PV anasto- TY, et al. Section 6. Management of extensive nontu-
mosis with minimal risk of PV twisting. morous portal vein thrombosis in adult living donor
liver transplantation. Transplantation. 2014;97(Suppl
8):S23–30.
13. Moon DB, Lee SG, Ahn C, Hwang S, Kim KH, Ha
References T, et al. Application of intraoperative cine-­portogram
to detect spontaneous portosystemic collaterals
1. Lee SG. A complete treatment of adult living donor missed by intraoperative doppler exam in adult liv-
liver transplantation: a review of surgical technique ing donor liver transplantation. Liver Transpl.
and current challenges to expand indication of 2007;13(9):1279–84.
patients. Am J Transpl. 2015;15(1):17–38. 14. Hwang S, Lee SG, Ahn CS, Kim KH, Moon DB, Ha
2. Hwang S, Lee SG, Ahn CS, Moon DB, Kim KH, TY, et al. Technique and outcome of autologous portal
Sung KB, et al. Morphometric and simulation analy- Y-graft interposition for anomalous right portal veins
ses of right hepatic vein reconstruction in adult liv- in living donor liver transplantation. Liver Transpl.
ing donor liver transplantation using right lobe grafts. 2009;15(4):427–34.
Liver Transpl. 2010;16(5):639–48. 15. Hwang S, Ha TY, Song GW, Jung DH, Moon DB, Ahn
3. Gyu Lee S, Min Park K, Hwang S, Hun Kim K, CS, et al. Conjoined unification Venoplasty for double
Nak Choi D, Hyung Joo S, et al. Modified right portal vein branches of right liver graft: 1-year experi-
liver graft from a living donor to prevent congestion. ence at a high-volume living donor liver transplanta-
Transplantation. 2002;74(1):54–9. tion center. J Gastrointest Surg. 2016;20(1):199–205.
 Hepatic Artery Anastomosis
26
Chul-Soo Ahn

Abstract Keywords

Hepatic Arterial Anastomosis is the most Living donor liver transplantation · Hepatic
important procedure in living donor liver trans- artery · Anastomosis · Right gastroepiploic
plantation. For optimal stump function, it is artery
critical to ensure meticulous and atraumatic
dissection of hepatic hilum in both the donor
and recipient operations. A partial graft artery 26.1 Introduction
is small and thin, especially with multiple
arteries. Therefore, a precise anastomotic tech- Hepatic Arterial Anastomosis (HAA), known as
nique is required for safe anastomosis with a the most important procedure in living donor
surgical microscope or loupes. In the recipient liver transplantation, is closely and directly
hilar dissection, each of the arterial stumps is related to the perioperative or postoperative
identified up to at least the second branches for results after transplantation. In living donor liver
size matching with the donor arterial stumps. transplantation, persistent portal high pressure
Interrupted or continuous anastomotic tech- may occur as a result of the small graft size pre-
niques are commonly used with several modi- cluding arterial blood flow, which may in turn
fications. For stumps that are too short, the increase arterial complications. It is necessary to
backwall first technique is useful, and this was use anastomotic techniques to achieve optimal
done here without stump rotation. It is prefer- results. After applying a surgical microscope in
able to subject all graft arterial stumps to anas- hepatic artery anastomosis, the arterial complica-
tomosis if possible. Following anastomosis, tions rates are significantly decreased [1]. The
doppler ultrasonography is performed to eval- microscope provides precise and meticulous
uate the patency. In the case of arterial throm- anastomosis with its sufficient magnification, but
bosis, early re-­ anastomosis with different a long training period is required for a surgeon to
health inflow is essential for graft saving. become familiar with this technique. Recently,
high magnification loupes have begun replacing
surgical microscopes in certain cases with com-
C.-S. Ahn (*) parable results. In addition, their indications are
Division of Hepatobiliary Surgery and Liver increasing as their experiences are increasing [2].
Transplantation, Department of Surgery, Asan
Medical Center, University of Ulsan College of
Medicine, Seoul, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 159

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_26
160 C.-S. Ahn

26.2 Graft Artery injury. It is important to identify all hepatic arter-

ies (left, middle, and right HA) up to their sec-
The size of a graft arterial stump is smaller than ond branches for size matching with the donor
those of whole liver grafts, and its mean diameter arterial stump [7]. After removing the recipient
is less than 3 cm (1–4 cm) [3]. More than 40% of liver, a vascular clamp should be placed at the
the left lobe grafts and 5% of the right lobe grafts proximal portion of the recipient arterial stump.
had multiple hepatic arteries [4, 5]. Although If the clamp is applied at the distal portion, the
graft hepatic artery stumps from a healthy donor tiny intimal tear during hilar dissection would
represent the highest tissue quality, they have thin worsen with forceful and pulsatile blood flow,
and weak arterial walls and make anastomosis which would result in transmural thrombosis in
difficult. During a graft harvest, the arterial stump the stump. When all recipient arterial stumps are
should be cut without tension to safely preserve injured, several arteries are used alternatively;
the arterial intima of both sides [3]. In the case of the right gastroepiploic artery is the most com-
multiple arteries, the nondominant stump should monly used because it is easy to mobilize with
be cut first to evaluate the backflow from its sufficient length and it can supply sufficient
stump with the intact dominant artery. In general, blood flow.
the recessive arterial stump is reconstructed or
ligated according to its back-bleeding quality
after dominant stump reconstruction. However, 26.4 Anastomosis Techniques
reconstructions of all feasible arterial stumps are
preferable for several reasons. For one, they There are several important factors for the selec-
restore the original anatomic blood supply. As tion of the inflow stump in the recipient, includ-
each stump of a multiple artery graft is smaller ing sufficient and pulsatile blood flow from the
and has a higher risk of complication, multiple stump, intimal tearing or thrombus or mural cal-
anastomosis may save the graft if one artery is cification by inspection, and size-matching
thrombosed. It can sometimes be difficult to between two stumps. Less than a twofold size
identify the dominant stump, and the nondomi- discrepancy is considered safe for direct anasto-
nant stump may be located deeper, making its mosis. All connective tissues outside of adventi-
reconstruction difficult or impossible if the domi- tia, which is potent thrombogenic material,
nant one has been reconstructed. should be trimmed to make the anastomotic site
round and smooth before suturing. The anasto-
motic site in the recipient is located deep inside
26.3 Recipient Artery and moves up and down with heartbeats and res-
piration. An approximator clamp, an atraumatic
Minimizing arterial injury is the most important double-armed clamp moving on a side bar, is an
consideration during recipient hilar dissection. essential instrument for HAA, as it substantially
Severe fibrosis and collateral vessels developed facilitates the procedure by providing orientation
from cirrhosis make the dissection of hilar struc- and tension-free anastomosis (Fig. 26.1). Nylon,
ture difficult. By hyperdynamic circulation, par- which is stronger than prolene, is a preferable
ticularly with portal hypertension, the hepatic suture material with an arterial diameter from 7.0
artery becomes stiffer with intimal hypertrophy to 10.0. During anastomosis, the needle should
or edema despite an increase in the diameter [6]. go through the whole thickness of the arterial
This pathologic condition makes the arterial wall wall with the right angle. Partial, not including
fragile and vulnerable to injury during hilar dis- intima, or oblique suture may result in transmural
section. Preoperative arterial intimal injury by hematoma or intimal folding, which may in turn
TACE and radiation are risk factors for arterial result in inner wall narrowing. When the intima is
thrombosis or stricture. thickened or divided from adventitia, an upward
During dissection, extensive traction of the forceps can be used to lift up the whole arterial
vessel should be avoided to prevent intimal wall (Fig. 26.2).
26 Hepatic Artery Anastomosis 161

Fig. 26.1 After complete removal of periadventitial tis-

sue, all arterial stumps were approximated for tension-­
free anastomosis using a double-armed clamp Fig. 26.2 The upward forceps were inserted into the vas-
cular lumen and used to lift up its wall to facilitate full-­
thickness suturing. This technique is very useful when
there is a thickened arterial wall with hypertrophy or inti-
mal edema and when the intimal layer is separated from
the adventitial layer

a b

Fig. 26.3 Sutures were placed in the middle of each of the stitches untied (a), and after evaluating the full thickness
and free backwall and confirming correct suture placement, all remnant sutures were tied (b)

Two types of anastomotic techniques are com- rotated and the same sutures are repeated on the
monly used: interrupted or continuous. Various posterior wall, which is now the anterior position
combined procedures of these are applicable in after the rotation. The continuous suture tech-
certain conditions. The interrupted suture tech- nique is easier and faster than the interrupted
nique starts with two stay sutures at the two lat- suture technique, but it has limitations such as a
eral edges of the vessels. Following sutures are small artery or suboptimal arterial stump, intimal
placed in the middle of each of the stitches untied edema, or detachment. The backwall first tech-
to allow easy inspection of the posterior wall. nique is used when the donor hepatic arterial
After evaluating the full thickness suture and free stump is too short for rotation and when the
backwall and confirming correct suture place- recipient arterial stump is fragile or diseased such
ment, all remnant sutures are tied at least three that the rotation might result in further damage
times (Fig. 26.3). Then, the approximator is [8]. After the first stay suture, the interrupted
162 C.-S. Ahn

technique begins with the donor side from the advantages compared with conventional procedures.
outside to the inside and the recipient side from Transplantation. 1992;54:263–8.
2. Li PC, Thorat A, Leng LB, Yang HR, et al. Hepatic
the inside to the outside, and it is tied with a knot artery reconstruction in living donor liver trans-
outside of the wall. The anterior wall is per- plantation using surgical loupes: achieving low rate
formed in the routine fashion described above. of hepatic arterial thrombosis in 741 consecutive
Recently, cases of arterial reconstruction using recipients-­tips and tricks to overcome the poor hepatic
arterial flow. Liver Transplant. 2017;23:887–98.
surgical loupes rather than microscopic equip- 3. Ahn CS, Lee SG, Hwang S, et al. Anatomic varia-
ment are increasing due to their convenience with tion of the right hepatic artery and its reconstruction
comparable results [2, 9]. However, to date, they for living donor liver transplantation using right lobe
have been applied in selective cases with suffi- graft. Transplant Proc. 2005;37:1067–9.
4. Ahn CS, Hwang S, Moon DB, et al. Right gastroepi-
cient size and healthy arterial stumps. The method ploic artery is the first alternative inflow source for
using surgical loupes has attracted criticism for hepatic arterial reconstruction in living donor liver
the resulting biliary complication and anasto- transplantation. Transplant Proc. 2012;44:451–3.
motic stricture [10]. 5. Uchiyama H, Harada N. Dual hepatic artery recon-
struction in living donor liver transplantation using
After anastomosis, doppler ultrasonography is a left graft with 2 hepatic arterial stumps. Surgery.
performed immediately to demonstrate the 2010;147:878–86.
patency of anastomosis. In the case of acute arte- 6. Balci D, Ahn CS. Hepatic artery reconstruction in
rial thrombosis, though it is rare, early re-­ living donor liver transplantation. Curr Opin Organ
Transplant. 2019;24:631–6.
anastomosis with different healthy inflow is 7. Harada N, Yoshizumi T, Uchiyama H, et al. Impact of
essential for graft saving. hepatic artery size mismatch between donor and recip-
In conclusion, atraumatic hilar dissection in ient on outcomes after living-donor liver transplanta-
both the donor and recipient operations ensures tion using right lobe. Clin Transpl. 2019;33:e13444.
8. Lee CF, Lu JC, Zidan A, et al. Microscope-assisted
that all of the stumps are healthy. The use of pre- hepatic artery reconstruction in adult living donor
cise and meticulous anastomotic techniques with liver transplantation—a review of 325 consecutive
suitable modification under sufficient magnifica- cases in single center. Clin Transpl. 2017;31:e12879.
tion is essential for arterial anastomosis. Further, 9. Yagi T, Shinoura S, Umeda Y, et al. Surgical rational-
ization living donor liver transplantation by abolition
for the survival of the graft or the patient, early of hepatic artery reconstruction under a fixed micro-
detection and early re-anastomosis are needed in scope. Clin Transpl. 2012;26:877–83.
acute arterial thrombosis. 10. Ikegami T, Yoshizumi T, Uchiyama H, et al. Hepatic
artery reconstruction in living donor liver trans-
plantation using surgical loupes: achieving low rate
of hepatic arterial thrombosis in 741 consecutive
recipients-­tips and tricks to overcome the poor hepatic
References arterial flow. Liver Transplant. 2017;23:1081–2.

1. Mori K, Nagata I, Yamagata S, et al. The introduc-

tion of microsurgery to hepatic artery reconstruction
in living-donor liver transplantation—its surgical
 Biliary Reconstruction
27
Bong-Wan Kim

Abstract
27.1 Chapter Outline
The duct-to-duct anastomosis is now the
standard procedure for biliary reconstruction The usefulness of duct-to-duct biliary reconstruc-
and has better outcomes than the hepaticoje- tion in living donor liver transplantation was first
junostomy reconstruction in living donor reported by Azoulay et al. in 2001 [1]. Since then,
liver transplantation (LDLT). There are some it has been widely used as a standard biliary pro-
technical principles that help to minimize cedure in almost all transplantation centers [2].
biliary complications after duct-to-duct anas- However, when the recipient’s biliary tract can-
tomosis such as intraoperative cholangiogra- not be spared, or when the condition of the bile
phy, tension-­ free and fine anastomosis, duct is not histologically suitable for anastomo-
avoiding electrocautery on duct openings, sis, Roux-en-Y hepaticojejunostomy must be
and duct-to-­ mucosa anastomosis. External performed. The essential techniques for a suc-
biliary stenting using small catheter might cessful duct-to-duct biliary reconstruction while
help to reduce bile leakage and ductoplasty minimizing postoperative complications are
for multiple graft ducts could facilitate duct- summarized below.
to-duct anastomosis.

Keywords 27.2 Method

Living donor liver transplantation 1. Cholangiography should be performed during
Duct-to-­duct anastomosis · Biliary donor hepatectomy
complication In some hospitals, the structure of the bili-
ary tract of the graft liver is analyzed using
preoperative MR cholangiography. However,
Supplementary Information The online version con- the use of intraoperative cholangiography can
tains supplementary material available at https://doi. generally provide more accurate information
org/10.1007/978-­981-­16-­1996-­0_27.
on the intrahepatic biliary tract structure than
MR cholangiography. By performing this pro-
B.-W. Kim (*) cedure, it is possible to grasp the exact cutting
Division of Hepatobiliary Surgery and Liver position of the biliary tract of the graft liver
Transplantation, Department of Surgery, Ajou
University School of Medicine, Suwon, South Korea while avoiding damage to the biliary tract of
e-mail: [email protected] the graft liver, and therefore preventing the

© Springer Nature Singapore Pte Ltd. 2023 163

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_27
164 B.-W. Kim

occurrence of biliary complications after and left hepatic ducts. Alternatively, an end-­
donor hepatectomy. to-­end anastomosis and an end-to-side anasto-
2. Ischemic damage to the graft’s and recipient’s mosis may be implemented to the recipient’s
biliary tracts must be avoided common bile duct, or a second anastomosis
To avoid ischemic damage to the graft liver may be performed at the recipient’s cystic
and to the biliary tract, hemostasis should be duct. Biliary anastomosis between the bile
performed around the bile duct through suture duct(s) of the graft liver and the recipient’s
ligation using small sutures of at least 6–0, biliary tract should be performed with sutures
rather than electrocautery. When cutting the of 6–0 or finer. The bile duct suture can be
biliary tract, it is also contraindicated to use performed by either continuous or interrupted
electric cauterization, and sharp Metzenbaum suture manner or by a continuous suture on
scissors must be used for cutting. Due to the the posterior wall and interrupted sutures on
cauterization, the subserosal capillaries the anterior wall. The selection of the anasto-
should not be grossly present. In addition, motic procedure depends on the preference
bleeding of the small arterioles should be and proficiency of the transplantation center,
observed on the cutting surface of the graft’s and there are no known differences in the
and recipient’s bile ducts. If ischemic damage postoperative outcomes of the different anas-
of the recipient’s biliary tract is suspected, or tomotic procedures. However, the principle of
if bleeding is not observed on the cut surface the suture manner is to not leave a thread knot
due to poor bile duct condition, Roux-en-Y in the biliary tract and to ensure that the suture
hepaticojejunostomy should be promptly per- interval is tight and delicate, not exceeding
formed instead of reconstruction. 1 mm. In terms of suture material selection,
3. When there are multiple bile duct openings on prolene is regarded to be better than a PDS
the cut edge with small distances between due to the reduced inflammation it causes, and
them, ductoplasty can be performed to com- the use of a fine suture technique with a 7-0 or
bine them into a single orifice during the 8-0 suture was reported to minimize biliary
back-table procedure. However, the bile ducts stricture [3].
must be separately anastomosed to the recipi- 6. In living donor liver transplantation, the size
ent’s bile duct when undue tension is expected of the bile duct of the graft liver is relatively
due to a large distance between them. small, measuring approximately 5 mm in
Generally, ductoplasty is considered safe if diameter, and there is a considerable disparity
the distance between the two bile ducts is less with the size of the recipient’s bile duct open-
than 7 mm. ing, which is approximately 10 mm in diam-
4. In a duct-to-duct biliary reconstruction, ten- eter. This discrepancy can typically be
sion should be avoided at the anastomosis of overcome by duct-to-mucosa anastomosis,
bile ducts. Excessive tension on the anasto- through which the graft bile duct is sewn to
mosis typically occurs as a result of the short the mucosal layer of the recipient’s bile duct
preparation of the recipient’s biliary. By con- [4, 5]. This is not only useful for overcoming
trast, the recipient’s biliary tract should not be the size discrepancy between the graft and
left too long, since it may bend after recipient bile ducts, but it can also enable
­anastomosis. The biliary tract of the recipient expansion growth of the graft’s bile duct.
should be cut with a Metzenbaum scissor to 7. Each transplantation center has its own pref-
an optimal length. erence of inserting an external catheter with a
5. The duct-to-duct biliary reconstruction may size between 3- and 4-Fr into the biliary tract,
be performed by an end-to-end anastomosis also known as “external biliary stenting”.
for a single bile duct. If two anastomoses are External biliary stenting can decompress the
required, the end-to-end anastomoses can be intraluminal pressure of the biliary tract after
performed separately to the recipient’s right LT, which can prevent post-transplant bile
27 Biliary Reconstruction 165

leakage, and which allows for postoperative References

cholangiography to be easily performed if
necessary [6]. In the case of a living donor 1. Azoulay D, Marin-Hargreaves G, Castaing D,
liver transplantation using the right lobe graft, ReneAdam BH. Duct-to-duct biliary anastomosis in
living related liver transplantation: the Paul Brousse
it is desirable that the biliary catheter be technique. Arch Surg. 2001;136(10):1197–200.
inserted into the graft’s posterior duct after https://doi.org/10.1001/archsurg.136.10.1197.
passing through the anastomosis site from a 2. Ishiko T, Egawa H, Kasahara M, Nakamura T, Oike
common bile duct, because the right posterior F, Kaihara S, et al. Duct-to-duct biliary reconstruc-
tion in living donor liver transplantation utilizing right
duct is more angulated in anatomical position. lobe graft. Ann Surg. 2002;236(2):235–40. https://doi.
The insertion of an internal biliary catheter org/10.1097/00000658-­200208000-­00012.
without the role of decompression is not rec- 3. Lin TS, Concejero AM, Chen CL, Chiang YC,
ommended because the stent can be easily Wang CC, Wang SH, et al. Routine microsurgical
biliary reconstruction decreases early anastomotic
dislodged and translocate to an unwarranted complications in living donor liver transplantation.
site in the biliary tract. Liver Transpl. 2009;15(12):1766–75. https://doi.
org/10.1002/lt.21947.
4. Kim BW, Bae BK, Lee JM, Won JH, Park YK, Xu
WG, et al. Duct-to-duct biliary reconstructions and
27.3 Conclusion complications in 100 living donor liver transplanta-
tions. Transplant Proc. 2009;41(5):1749–55. https://
In living donor liver transplantation, biliary com- doi.org/10.1016/j.transproceed.2009.02.097.
plications can be minimized by abiding the prin- 5. Kim SH, Lee KW, Kim YK, Cho SY, Han SS, Park
SJ. Tailored telescopic reconstruction of the bile
ciples described above, and by using delicate and duct in living donor liver transplantation. Liver
proficient techniques for biliary reconstruction. Transpl. 2010;16(9):1069–74. https://doi.org/10.1002/
In addition, the biliary reconstruction technique lt.22116.
can be differentially modified and developed for 6. Hong SY, Hu XG, Lee HY, Won JH, Kim JW, Shen XY,
et al. Long-term analysis of biliary complications after
logical and rational reasons for each transplanta- duct-to-duct biliary reconstruction in living donor liver
tion center or surgeon, which is thought to further transplantations. Liver Transpl. 2018;24(8):1050–61.
reduce the occurrence of postoperative biliary https://doi.org/10.1002/lt.25074.
complications.
 Part IV
Cholecystectomy
 Laparoscopic Cholecystectomy
(3–4 Ports Method) 28
Sang Mok Lee

Abstract Keywords

Laparoscopic cholecystectomy (LC) is a sur- Laparoscopic cholecystectomy

gical method that is considered the gold stan- Laparoscopic surgery · Critical view of safety
dard for the treatment of symptomatic GB Bile duct injury · Technical variations
stones, and it is recognized as an alternative to
open cholecystectomy (OC). Although LC is a
very safe operation, one must be familiar with 28.1 Introduction
all the different instruments used in a LC, and
one should be able to perform an OC on top of Because of the advantages of laparoscopic sur-
acquiring the basic techniques needed for lap- gery (LS), laparoscopic cholecystectomy (LC) is
aroscopic surgery (LS). The most serious a surgical method that is considered the gold
complication of LS is bile duct injury. To min- standard for the treatment of symptomatic GB
imize the risk of bile duct injury, widening stones, and it is recognized as an alternative to
Calot’s triangle and taking a critical view of open cholecystectomy (OC) according to the sur-
safety are the most important steps, along with geon’s experience and skills with various instru-
avoiding thermal injury. ments. Although LC is a very safe operation, it is
A variety of technical variations for LC performed using instruments that are restricted in
have recently been introduced to minimize the use and make it so that the surgeon cannot feel by
invasiveness while reducing the size and num- touch, and it therefore requires experience and
ber of ports to improve the cosmetic and post- has limitations in indications. This means that
operative outcomes. surgeons have to choose between OC or LC to
map out a strategy before surgery. Since LC is an
operation that uses many kinds of instruments,
one must be familiar with all the instruments, and
they should also be able to do simple first aid in
Supplementary Information The online version con-
tains supplementary material available at https://doi.
the event of instrumental problems.
org/10.1007/978-­981-­16-­1996-­0_28.

S. M. Lee (*)
Department of Surgery, Kyung Hee University
College of Medicine, Seoul, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 169

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_28
170 S. M. Lee

Recently, a variety of technical variations for 28.4 Patient’s Posture

LC have been introduced to minimize the inva- and Arrangement
siveness while reducing the size and number of of Equipment and Personnel
ports to improve cosmetic and postoperative out-
comes. Here, I would like to explain the surgical 1. Patient’s posture—the left arm is lowered to
method of LC with three or four ports in terms of the torso and the right arm is extended to 90°
the technical aspects involved. for easy installation and management of the
IV and A line.
2. Place a monitor on each side of the patient.
28.2 Preoperative Preparation The monitor located on the right side of the
patient is attached with a CO2 insufflator and
You should have a good understanding of the optic equipment for both the operator and the
anatomical structure of the hepatobiliary system, camera assistant.
you should be able to perform an OC, and you 3. Both the operator and the camera assistant
must have fully acquired the basic techniques of should be on the left side of the patient, while
LS [1]. the first assistant should be on the right side of
the patient.
1. Make sure the preoperative diagnosis is
correct.
2. Prior to surgery, identify past medical history 28.5 Surgical Techniques
and clinical patterns, then conduct various
examinations and confirm inflammation, 1. Creation of CO2 Pneumoperitoneum
fibrosis, and anatomical variation around the The patient is placed in a mild
gallbladder via imaging. Trendelenburg position. A small periumbilical
3. Check the combined diseases and the medi- incision is made according to the patient’s sta-
cine currently being taken, and ensure that the tus and the surgeon’s preference as well as
patient is able to undergo general anesthesia. cosmetic considerations following one of two
It is particularly important to confirm the use techniques: a closed technique or an open
of anticoagulants. technique. I prefer the closed technique using
4. Insert the Foley catheter only if the operation a Veress needle.
is expected to be prolonged. It is recom- (1) Closed Technique Using a Veress Needle
mended to selectively insert the nasogastric (a) Skin incision: A 1 cm skin incision is
tube only if the stomach or duodenum is made vertically along the crease
highly dilated after forming pneumoperito- inside the navel or horizontally along
neum to the point of potentially interfering the crease outside of the navel. The
with the surgery. vertical incision is easier but has a
5. The operating table should be remotely adjust- larger cosmetic effect.
able and suitable for performing intraopera- (b) Insertion of the Veress needle: After
tive cholangiography during LC. skin incision, bluntly dissect the sub-
cutaneous fat with scissors or clamps
to expose the fascia and grasp the
28.3 Anesthesia abdominal wall on either side of the
umbilicus; both the skin and the fas-
General anesthesia and endotracheal intubation cia should be penetrated by breast
are recommended. clamps or towel clips to lift the
28 Laparoscopic Cholecystectomy (3–4 Ports Method) 171

abdominal wall. After lifting the To verify a safe opening into the peri-
abdominal wall, the Veress needle, toneal space, insert the fifth finger and
held gently as if one were throwing a palpate the region around the opening.
dart, is inserted into the abdominal 2. Insertion of Trocars
cavity through the fascia and the peri- After removing the Veress needle, insert a
toneum, where a characteristic pop- 10 mm disposal trocar into the peritoneal cav-
ping sensation can be felt. ity while lifting the abdominal wall. While
(c) Verification of location and patency holding the end of the trocar deep in the palm
of the Veress needle: These are of the hand and extending the middle finger
respectively verified by repeated irri- along the trocar (Fig. 28.1), the trocar should
gation of clear normal saline in and be inserted gently in a twisting motion. This
out of the peritoneal cavity (syringe method can prevent excessive insertion of the
test), and by the dropped normal trocar. Then, the videoscope (either flat or
saline in the translucent herb of the angled) can be inserted through the first trocar
Veress needle being drawn into the (umbilical port), and a brief examination of
peritoneal cavity when the abdominal the abdominal cavity can be made for any
wall is lifted (drop test). organ pathology, adhesions, or trocar-induced
(d) Creation of pneumoperitoneum: injuries.
After insertion of the Veress needle, Two or three additional trocars are then
CO2 gas insufflation begins at a low inserted under direct vision. In the four-port
flow rate (1–3 L/min) while watching method, the second 5- or 10-mm trocar (epi-
the intra-abdominal pressure and gastric port) is inserted into the epigastrium in
insufflating flow rate. Once the abdo- about the upper 2/3 portion between the umbi-
men has expanded to a certain extent, licus and the xiphoid process, immediately to
you should hear a tympanic sound the right of the falciform ligament. The third
when percussing the abdomen. The trocar (5 mm, traction port) is inserted into the
flow rate and the intra-abdominal RUQ abdomen near the midclavicular line,
pressure may increase without neces- 3–4 cm below the costal margin. The fourth
sarily indicating a problem. However, trocar (5 mm, lateral port) is inserted in the
if there is a sudden intra-abdominal anterior axillary 4–5 cm below the costal mar-
pressure rise or asymmetric abdomi- gin. Because there are personal variations and
nal expansion, the gas insufflation differences in the anatomical structure, I insert
should be stopped and the cause
should be investigated. When the
intra-abdominal pressure reaches the
preset limitation (12–15 cm H2O),
the Veress needle should be removed.
(2) Closed Technique
Skin incision and exposure of the fas-
cia are the same as in the closed tech-
nique. When the fascia is exposed, hold
either side of the fascia with Kelly clamps
and open the fascia while checking the
preperitoneal fat or the peritoneum. Then,
with the peritoneum elevated, cautiously
open it with a finger or a scalpel and per-
form a pair of lateral stay sutures includ- Fig. 28.1 Shape of the hand and fingers grasping a trocar
ing the peritoneum and the fascia. for the umbilical port
172 S. M. Lee

the trocar according to the particular anatomi- The GB infundibulum is grasped with
cal structure. I insert the second trocar 2–3 cm the forceps through the traction port and
below the liver margin, immediately to the lifted to the upper right of the patient for
right of the falciform ligament. Every trocar is full exposure and identification of
inserted at an angle of 90° so it can be easily Calot’s triangle and the extrahepatic bile
moved in any direction. In the three-port duct. Prior to the dissection of Calot’s
method, the traction port is inserted more lat- triangle, correctly identifying the anat-
erally than it is in the four-port method, as this omy of Calot’s triangle and the extrahe-
is advantageous for an instrument that is patic duct may reduce bile duct injury. If
opened a lot. there is some anatomical distortion, the
Compared to the four-port method, the round ligament and S4 segment of the
three-port method is less invasive, more eco- liver can be good anatomical landmarks,
nomical, and has better cosmetic outcomes, because the confluence of the bile duct
but it is difficult to secure a surgical field for is located on the S4 between the GB and
this method and to cope with any unforeseen round ligament (Fig. 28.2a, b). As a
circumstances that arise. Therefore, the three-­ grossly distended GB makes grasping
port method is only recommended after hav- difficult and is more susceptible to rup-
ing accumulated enough experience with the turing, puncture and aspiration of the
four-port method [2]. The basic four-port GB are recommended.
method usually uses 5 mm trocars in all ports (4) Widening Calot’s triangle and dissection
except the umbilical port. Recently, many sur- of the cystic duct and cystic artery: Both
geons have inserted one 5 mm trocar alone as aspects of serosa over the presumed
the epigastric port while using 2 or 3 mm tro- junction of the GB and cystic duct
cars for the other ports to reduce the invasive- should be opened as widely as possible
ness and improve the cosmetic outcomes. (i.e., widening Calot’s triangle) with dis-
3. Cholecystectomy secting forceps or a hook cautery
(1) A general examination of the abdominal through the epigastric port. The cystic
cavity and exposure of the gallbladder duct and artery are exposed circumfer-
(GB): After all trocars have been entially with a gentle teasing and spread-
inserted, the pelvic cavity is first ing motion while checking with the
observed by taking a slight reverse eyes, and the GB infundibulum is also
Trendelenburg position and then chang- fully dissected and exposed from the
ing the posture to a 10–15° right-side up liver (i.e., unfolding Calot’s triangle)
position; this maneuver achieves full [3]. The dissection is initiated high in
exposure and allows for observation of the cystic duct or the GB infundibulum,
the ileocecal region, ascending colon, and blunt dissection is preferable in the
and GB. connective tissue. After identifying the
(2) Securing surgical space: The fundus of continuous connection between the cys-
the GB is grasped with a ratcheted for- tic duct and the GB infundibulum and
ceps through the lateral port, then the identifying the liver that is seen poste-
GB and liver are lifted to the upper right rior to Calot’s triangle (i.e., taking a
of the patient to provide good exposure critical view of safety), the cystic duct
of the GB. Rather than lifting, pushing and artery are clipped and divided to
the GB with the feeling of propping up minimize bile duct injury [4].
the forceps against the liver may reduce If there is a lot of fat or severe edema
the damage to the GB and the liver. in Calot’s triangle, aspiration of fat or
(3) Exposure and identification of Calot’s edematous tissue using a suction device
triangle and the extrahepatic bile duct: will help identify the anatomical struc-
28 Laparoscopic Cholecystectomy (3–4 Ports Method) 173

a b

Fig. 28.2 (a) Identification of the common duct; (b) The groove (white arrow) lateral to the common duct CBD com-
mon bile duct, CHD common hepatic duct

ture. A suction device may be a good

blunt dissector as a CUSA. If the cystic
duct is clipped near the common duct
with too much traction, the bile duct can
potentially narrow. Surgical clips should
be applied at an angle of 90° without
twisting and loosening. If there is a case
in which the cystic duct and artery are
respectively divided, it is better to cut
the artery first, if at all possible. If the
cystic duct is divided first, care should
be taken not to tear the cystic artery dur-
Fig. 28.3 Dissection of the GB from the liver bed
ing the GB pull. To prevent thermal
injury, the division must be done with
scissors rather than electrocautery. bleeding from the GB bed. The only
(5) Dissection of the GB from the liver bed: known prophylactic measure to reduce
After dividing the cystic duct and the bile from the bile ducts of Luschka is to
artery, grasp and properly pull the GB dissect as close as possible to the GB
with two forceps through the lateral port wall [5].
and the traction port, and open the GB (6) Put the resected GB in a retrieval bag:
serosa longitudinally about 1 cm away The telescope in the umbilical port is
from the liver with a hook cautery pulled out and an endoscopic removal
(Fig. 28.3). Then, grasp the GB infun- bag is inserted. After removing the sleeve,
dibulum with forceps through the trac- only a retrieval bag is left in the abdomi-
tion port, and proceed with the dissection nal cavity, and after reinsertion of the
of the GB with electrocautery from the telescope the bag is unfolded on the liver
liver bed following from the infundibu- dome under direct vision using two for-
lum to the fundus of the GB (i.e., retro- ceps through the epigastric and traction
grade cholecystectomy); in selected port. The resected GB is then put in the
cases, antegrade cholecystectomy may bag and placed in the pouch between the
be easier. Care should be taken to keep liver and diaphragm. Some surgeons put
the dissection in the right plane and in an endoscopic removal bag through the
close to the GB wall, which can prevent epigastric port using a 10 mm trocar.
174 S. M. Lee

(7) Examination of the dissected area: sufficiently clearing and identifying the
Careful examination of the dissected cystic duct and artery, the artery is
area is recommended while lifting the clipped and divided. The cystic duct is
liver with forceps and grasping the clipped as high as possible close to the
remaining GB serosa that is still attached infundibulum, and an anterolateral duc-
to the liver (Fig. 28.4). Bleeding and bile totomy is made distal to the clip. A chol-
leaks must be checked for and controlled angiogram catheter is inserted through
as well. A visual inspection should be the ductotomy and secured in place
made first, after which irrigation and using cholangiogram forceps. Air in the
suction are recommended. If either bile duct and the catheter should be
bleeding or bile leaks are suspected, removed before cholangiography. It is
control without hesitation. If there is better to identify the bile leaks through
bleeding that is difficult to control from the ductotomy before inserting a cholan-
the exposed portal vein in the liver bed, giogram catheter, and it is recommended
compression with a retrieval bag filled to do so without wasting a lot of time or
with the resected GB using sufficient effort.
blood clot-inducing materials for a few (10) Removal of the trocars and extraction of
minutes is safer and more effective than the resected GB: Before removing the
bleeding control with electrocautery or trocars, careful examination of the
suture. bleeding and bile leakage in the dis-
(8) Perforation of the GB: If perforation of sected area and of the upper abdomen
the GB occurs during surgery, measures should be done, and drains should be
to minimize any significant spillage installed when necessary without hesita-
should be taken. Putting stones in a pre- tion. The ports are removed under direct
loaded retrieval bag after aspiration of vision to evaluate possible bleeding,
bile may also be needed. Complete then the resected GB in the bag is
removal of spilt stones and sufficient extracted with the umbilical trocar. If the
irrigation are likely necessary, and one extraction is too difficult because of an
should not hesitate to insert a drainage excessively thick wall of the GB or
catheter. exceedingly large stones, you do not
(9) Intraoperative cholangiogram (IOC): need to extend the incision if the GB or
IOC is needed in selected cases. After the stones are kept in the bag while cut-
ting the GB with scissors or crushing the
stones with forceps. All specimens
should be placed and removed in a
retrieval bag.
(11) Closure of incisions: The fascial defects
in the 10 mm port are sutured with
absorbable sutures (2–0 size, 3/4 circled
and atraumatic needle is preferred).
While suturing the defect in the umbilical
port, I prefer to perform the suture includ-
ing the peritoneum and the fascia with
my own eyes while lifting the fascia with
Fig. 28.4 Examination of the dissected area after com- the clamps. The skin is approximated
pletion of cholecystectomy with absorbable subcutaneous sutures.
28 Laparoscopic Cholecystectomy (3–4 Ports Method) 175

28.6 Microlaparoscopic GB, because 2 mm instruments are small and

Cholecystectomy weak. Therefore, to achieve good exposure, I push
rather than pull the GB while keeping the forceps
LC may be done to reduce the size and/or number in an open position. When dissecting Calot’s tri-
of trocars to minimize invasiveness with improved angle, the GB is pulled with the forceps to make a
cosmetic and postoperative outcomes. If LC is wedge form and remain in an open position
performed using 2 or 3 mm ports except for the between the dissected tissues or between the cys-
umbilical port, it is called “microlaparoscopic tic duct and artery (Fig. 28.5a, b). Another draw-
cholecystectomy” (micro-LC). In micro-LC, the back of micro-LC is that a 2 mm telescope placed
cosmetic effect and the postoperative outcomes through the epigastric port shows a dark and low-
are good because of the decreased invasiveness resolution image when clipping the cystic duct
due to the reduce size of the trocars, but there are and artery with endoscopic clips through the
restrictions on the use of the instruments, which umbilical port. Therefore, 2 mm telescopes are
make the operation difficult and the indications recommended for use in a temporary and auxil-
narrow [6]. As a result, some surgeons use self-­ iary manner. Despite the disadvantages of micro-
made instruments, and instrument-optimized LC, it achieves good postoperative outcomes with
techniques are needed. I use 2 mm trocars as well high patient satisfaction. It is also easier to learn
as a self-made hook electrocautery and suction-­ compared to single port LC, and it can be used in
irrigation device. It is difficult to grasp and lift the selected patients with acute cholecystitis [6].

a b

Fig. 28.5 (a, b) Traction of the GB with 2 mm forceps between the dissected tissues (a) or between the cystic
through the traction port of the GB, with the forceps mak- duct and the artery (b)
ing a wedge form and remaining in an open position
176 S. M. Lee

References 4. Strasberg SM, Hertl M, Soper NJ. An analysis of the

problem of biliary injury during laparoscopic chole-
cystectomy. J Am Coll Surg. 1995;180:101–25.
1. Kim SH, Seo KS. Hepato-biliary-pancreatic surgery.
5. Spanos CP, Syrakos T. Bile leaks from the duct of
3rd ed. Euihak Co: Seoul; 2013.
Luschka (subvesical duct): a review. Langenbeck's
2. Hur SH, Lee SM, Koh SH, et al. The usefulness of
Arch Surg. 2006;391:441–7.
three-portal technique for laparoscopic cholecystec-
6. Kwon TS, Lee SM, Park SJ, et al. Clinical application
tomy. JMIS. 1999;2(2):41–8.
of 2 mm trocar mini-laparoscopic cholecystectomy.
3. Ellison EC, Zollinger RM Jr. Zollinger’s atlas of surgi-
JMIS. 2007;10:79–82.
cal operations. 10th ed. Mc Graw Hill; 2016.
 Laparoscopic Single-Site
Cholecystectomy 29
(Single Port Method)

Dong-Hoon Shin

Abstract The surgeon performs surgery on the left

side of the patient and the first assistant helps
In benign gallbladder disease, laparoscopic
the puncture for insertion (trocar insertion) on
cholecystectomy is a standard technique.
the right side of the patient, and if necessary,
However, laparoscopic single-incision (single
moves to the left of the patient to catch a lapa-
port) cholecystectomy is known to be gener-
roscopic camera next to the surgeon. The
ally unacceptable for patients with severe
patient’s left arm is attached next to the
acute cholecystitis, chronic cholecystitis, and
patient’s body, and the right arm is placed on
gall stone-related pancreatitis. In addition,
the armrest slot with open sideways. The
though there is not an official standard, it is
monitor is best placed in the position of the
known to be difficult to conduct surgery with
patient’s right shoulder.
patients with a high BMI. However, regardless
2. Puncture Area
of difficult cases, the range of laparoscopic
In the case of three-port or four-port sur-
single-incision cholecystectomy is increas-
gery, a trocar is inserted a 10 mm or 5 mm
ingly expanding by the development of the
around the navel. Laparoscopic single-­
mechanism and the technique.
incision cholecystectomy requires a slightly
larger hole than the three-port or four-port
Keywords
method. It is advantageous to make a hole by
Single port · Single incision · Single site making a vertical incision in the middle of the
Gallbladder · Laparoscopy · Cholecystectomy navel to insert a single-incision surgical trocar
to obtain efficiency with a relatively small
skin incision (Fig. 29.1). If the subcutaneous
29.1 Surgical Procedures fat is too thick to expose the fascia, piercing
the abdominal wall while lifting the bottom of
1. Preparing the Operating Room the navel using the Kocher clamp is another
way. The single-incision surgical trocar can
be used by surgeons using surgical gloves and
Supplementary Information The online version con-
wound retractors. However, more surgeons
tains supplementary material available at https://doi.
org/10.1007/978-­981-­16-­1996-­0_29. use commercially available trocars today.
After the incision of the peritoneal membrane
is sufficiently made, while retracting the
D.-H. Shin (*) abdominal wall including the peritoneal mem-
Kosin University Hospital, Busan, South Korea

© Springer Nature Singapore Pte Ltd. 2023 177

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_29
178 D.-H. Shin

Fig. 29.3 Install a single-incision surgical trocar and

Fig. 29.1 Make a hole by making a vertical incision in make pneumoperitoneum
the middle of the navel

Fig. 29.4 Use a telescope to check intraperitoneal

conditions
Fig. 29.2 Insert a single-incision surgical trocar

brane, insert a single-incision surgical trocar

and make a pneumoperitoneum while main-
taining the pressure at 12–14 mmHg
(Figs. 29.2 and 29.3).
3. Surgical Techniques
Use 0–30° telescope or flexible telescope.
Check the organs behind the pelvis and
abdominal wall, and make sure that there is
no damage that occurred when inserting the
­trocar (Fig. 29.4). In order to expose the gall-
bladder, make reverse Trendelenburg posi- Fig. 29.5 Hold the fundus of the gallbladder with endo-
tion by raising the patient’s head direction by grasper and expose it around the gallbladder
about 30°. Raising the right side of the oper-
ating table also helps to expose the gallblad- endodissector or right-angled dissector with
der. By inserting the endograsper with the the right hand to hold the body of the gall-
left hand, hold the fundus of the gallbladder bladder, and use the endograsper held with
and expose the surroundings of the cystic the left hand to help to hold the fundus of the
duct of the gallbladder (Fig. 29.5). Use the gallbladder in precision. Retract the endo-
29 Laparoscopic Single-Site Cholecystectomy (Single Port Method) 179

Fig. 29.7 Dissect cystic artery

Fig. 29.6 Exposing the triangle of Calot, use endodissec-

tor to perform dissection starting with the infundibulum of tion must be performed after finding the exact
the gallbladder toward the cystic duct cystic duct and cystic artery.
If the cystic duct and cystic artery are
grasper to the right outer side of the patient ligated and cut, use endograsper of the left
to expose the triangle of Callot. Using the hand to hold the fundus or body of the gall-
endodissector with the right hand, perform bladder and retract it toward the patient’s head
dissection from the gallbladder toward the or right outer side of the patient. While doing
cystic duct. Finding the best angle to retract so, perform dissection using suitable endodis-
while moving the endograsper of the left sector instruments through electrocautery.
hand properly, it is recommended to perform While performing a dissection, make sure that
dissection while ensuring sufficient traction there is no bleeding site. If there is bleeding,
to ensure the surgical view (Fig. 29.6). If the control bleeding through electrocautery and
gallbladder ligation is done properly, hold ligation. The dissected gallbladder should be
the scissors with your right hand and care- removed through the trocar site located at the
fully cut the gallbladder. At this time, it navel.
should be careful not to cut the tissue located The fascia of the abdominal wall is usually
in the back of the cystic duct because the closed with suitable suture materials such as
angle of the scissors enters from the front. polypropylene sutures, and subcuticular clo-
It should be careful not to damage the cys- sure should be performed for the dermis of the
tic artery or hepatic artery that passes behind umbilicus.
the cystic duct. If the gallbladder is cut off,
use endograsper of the left hand to retract the
fundus of the gallbladder carefully toward the 29.2 Conclusion
patient’s head, i.e., the liver edge. While doing
so, use endodissector or right-angled endodis- Laparoscopic single-incision cholecystectomy
sector of the right hand to dissect the cystic is a safe and efficient surgical method as much
artery (it is also possible to expose both cystic as the three-port or four-port laparoscopic cho-
duct and cystic artery through dissection at lecystectomy [1–3]. Although the indications
the same time). If it is confirmed that it is the of surgery of single-incision laparoscopic cho-
cystic artery, performs ligation and dissection lecystectomy are still limited compared to the
with the right hand (Fig. 29.7). three-port or four-port method, especially if
In the technique of cholecystectomy, it is the anatomical classification of the gallbladder
crucial to prevent damages of surrounding is difficult for inflammatory diseases or other
organs such as common bile duct or hepatic reasons, the effort to expand the indications
artery, etc. Therefore, the ligation and dissec- continues [4].
180 D.-H. Shin

References parison of single incision laparoscopic cholecystec-

tomy and three port laparoscopic cholecystectomy:
prospective randomized study. J Korean Surg Soc.
1. Romanelli JR, Roshek TB 3rd, Lynn DC, et al. Single-­
2013;85:275–82.
port laparoscopic cholecystectomy: initial experience.
4. Kim HS, Han Y, Kang JS, et al. Comparison of single-­
Surg Endosc. 2010;24:1374–9.
incision robotic cholecystectomy, single–incision
2. Bucher P, Pusin F, Buchs NC, et al. Randomised
laparoscopic cholecystectomy and 3-port laparoscopic
clinical trial of laparoscopic single-site versus con-
cholecystectomy-postoperative pain, cosmetic out-
ventional laparoscopic cholecystectomy. Br J Surg.
come and Surgeon’s workload. J Minim Invasive Surg.
2011;98:1695–702.
2018;21(4):168–76.
3. Deveci U, Barbaros U, Kapakli MS, Manukyan
MN, Şimşek S, Kebudi A, Mercan S. The com-
 Laparoscopic Surgery
for Gallbladder Polyps 30
and Early-­Stage Gallbladder
Cancer

Woo-Jung Lee and Myung Jae Jung

Abstract 30.1 Gallbladder Polyps

Laparoscopic cholecystectomy is widely per- and Early-Stage Gallbladder
formed, to treat such benign gallbladder dis- Cancer
eases as gallbladder polyps and cholecystitis.
Recently, it is even implemented for early 30.1.1 Overview
gallbladder cancers in a selective group of
patients. However, it must be applied with This chapter discusses the laparoscopic surgical
caution, since lymph node dissection is not technique used to treat gallbladder polyps and
always readily performed by laparoscopic sur- early-stage gallbladder cancer. Both diseases are
gery. In this chapter, implication of the proce- commonly treated with laparoscopic cholecys-
dure and principles to be followed during tectomy, and extended cholecystectomy (chole-
laparoscopic cholecystectomy are discussed. cystectomy + lymphadenectomy) should be
considered for early-stage gallbladder cancers
Keywords (T1b or higher). This chapter will first describe
laparoscopic cholecystectomy, then lymphade-
Laparoscopic cholecystectomy · Gallbladder nectomy. Prior to the surgical techniques, a brief
polyp · Early gallbladder cancer · Calot’s introduction of gallbladder polyps and early-
triangle · Four-port technique · Single-port stage gallbladder cancer is presented before the
technique · Radical cholecystectomy surgical techniques are described.
Lymphadenectomy

30.1.2 Gallbladder Polyps

Gallbladder polyps, mostly asymptomatic, are

often found incidentally on abdominal ultrasound
W.-J. Lee (*)
Yonsei University Severance Hospital, and computed tomogrhaphy. They are usually
Seoul, South Korea finally diagosed as cholesterol polyp or adenoma
e-mail: [email protected] (Fig. 30.1). Adenomas may be associated with a
M. J. Jung higher risk of malignant transformation with an
Myongji Hospital, iGoyand-si, increase in the size of the polyps. However,
Gyeonggi-do, South Korea

© Springer Nature Singapore Pte Ltd. 2023 181

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_30
182 W.-J. Lee and M. J. Jung

a b

Fig. 30.1 (a) Cholesterol polyp, (b) gallbladder adenoma

because it is difficult to differentiate between cholecystectomy, would improve the survival

adenoma and cholesterol polyps using the afore- rate of patients with T1b stage gallbladder can-
mentioned method, cholecystectomy is indicated cer. Moreover, several studies have reported no
for polyps ≥10 mm. difference in 5 year survival rates between
patients who underwent laparoscopic cholecys-
tectomy and those who underwent open surgery,
30.1.3 Early-Stage Gallbladder suggesting that open cholecystectomy may not
Cancer be necessary. However, a systematic literature
review of studies that reported on T1b-stage gall-
Although there is no clear definition, early-stage bladder cancer identified a lymph node metasta-
gallbladder cancer is considered to be the case sis rate of approximately 10% and a relapse rate
when invasion of the cancer cells is restricted to of 9–10%. Thus, lymphadenectomy can be rec-
the mucous membrane (T1a) or muscular layer ommended in patients without high operative
(T1b) of the gallbladder. Current guidelines rec- risk, and this aspect will be discussed further in a
ommend laparotomy in patients with suspected later section [4, 5].
gallbladder cancer based on preoperative evalua-
tion. However, many recent studies have
recommended simple cholecystectomy for
­ 30.2 Surgical Techniques
T1-stage gallbladder cancer. Further, laparo-
scopic cholecystectomy has shown outcomes 30.2.1 Laparoscopic
similar or superior to those of open cholecystec- Cholecystectomy
tomy, and the former procedure has therefore
gained popularity in the treatment of early-stage 30.2.1.1 Positioning of Patients
gallbladder cancer [1, 2]. Patients should be placed in the supine position,
In patients with T1a-stage gallbladder can- as in traditional abdominal surgeries. The
cer, a five-year survival rate of 95–100%, along patient’s left arm may be folded toward the body
with a minor 1% relapse rate, can be achieved to prevent interference with the surgeon and the
with simple cholecystectomy alone, thus avoid- first assistant, who both perform the surgery
ing the need for extended cholecystectomy. while standing on the left side of the patient.
Lymphadenectomy is not recommended in After disinfecting and covering the patient with a
patients with T1a-stage gallbladder cancer, as surgical drape, the laparoscope is inserted
the rate of lymph node metastasis has been through an incision either at the umbilicus or on
reported to be <2.5% [3]. the upper or lower side of the umbilicus, depend-
There is no reliable evidence indicating that ing on the surgeon’s preference. Next, the
extended cholecystectomy, compared to simple patient’s head is turned upward by approximately
30 Laparoscopic Surgery for Gallbladder Polyps and Early-Stage Gallbladder Cancer 183

30° (in reverse Trendelenburg position), then the laparoscopically, after which the remaining tro-
patient is turned to the left, which is the ideal cars can be inserted.
position for laparoscopic cholecystectomy. Laparoscopic cholecystectomy is commonly
performed using the four-port technique, wherein
30.2.1.2 Incision and Trocar Insertion one 12-mm camera trocar and three 5-mm trocars
As explained previously, an incision is made to are inserted. On the other hand, only two 5-mm
insert the laparoscope. Different operators have trocars are inserted in the three-port technique,
different preferences for insertion, which can which has recently come to be widely adopted.
largely be divided into the incision method and Likewise, single-port cholecystectomy is also
the closed entry method. A 12-mm camera trocar gaining popularity. However, the author usually
is inserted either through the umbilicus or through performs laparoscopic cholecystectomy using the
vertical or transverse incisions on the upper or four-port technique, and only applies the single-­
lower side of the umbilicus (Fig. 30.2a). While port technique in selected patients (young
both methods have their own advantages, the women, nonobese patients, and those without
author prefers the open method in which the tro- severe inflammation). Therefore, the four-port
car is inserted through the umbilicus. This tech- technique, which is performed most commonly,
nique obtains enhanced cosmetic results and will be discussed here.
enables the expansion of the incision to remove The camera troca is inserted in umbilical port.
the gallbladder after the surgery. And the second trocar is inserted at the upper-­third
After the laparoscope has been inserted position along the line between the umbilicus and
through the first trocar, the surgeon should check xyphoid process, the third trocar is inserted 2 cm
for intra-abdominal adhesions and anatomical below the intercostal end along the midline of the
deformities, as well as the degree of inflamma- right axilla, and the fourth trocar is inserted at the
tion in the gallbladder. Based on this assessment, point where the lateral line passes the second tro-
the decision may be made to perform the surgery car and the line below the papilla (Fig. 30.2b).

a b

Fig. 30.2 (a) Position of the camera port trocar, (b) position of the working port trocar
184 W.-J. Lee and M. J. Jung

30.2.1.3 Surgical Sequence gallbladder. In such cases, the adhesions should

First, the surgeon should insert a grasper through first be separated to facilitate retraction of the
the third trocar, then retract the fundus of the gall- gallbladder. Then, a hook or dissector attached to
bladder to the 11-o’clock position of the patient a monopolar surgical unit should be inserted
(right side toward the head), and have the second through the second trocar, followed by the inser-
assistant hold or fix it using a tool (Fig. 30.3a). tion of the grasper through the third trocar. At this
The degree of retraction must be controlled to point, it is important to pull the gallbladder toward
ensure adequate exposure of Calot’s triangle. In the surgeon while holding the gallbladder neck
some cases, the bottom part of the right liver may with a grasper inserted through the fourth trocar
be adhered to the transverse colon or to Gerota’s (Fig. 30.3b). Most beginners perform the surgery
fascia, thereby interfering with retraction of the by pushing the gallbladder backward, which

a b

c d

Fig. 30.3 (a) Retraction of the fundus of the gallbladder to the 11-o’clock position, (b) Pulling the gallbladder neck
toward the surgeon to expose the Calot’s triangle, (c) Resection of the cystic artery, (d) Robotic view of
cholecystectomy
30 Laparoscopic Surgery for Gallbladder Polyps and Early-Stage Gallbladder Cancer 185

makes it difficult to expose the cystic duct, thus the left hand. Upon complete sublation of the
causing damage to the common bile duct. It is gallbladder from the liver, the operator should
therefore important to assess the course of the insert a plastic bag, place the gallbladder in the
common bile duct by examining Calot’s triangle bag, and remove it through the camera trocar,
while pulling the cystic duct with the grasper. indicating completion of the surgery. The excised
During the identification of the common bile duct, gallbladder must be dissected and the polyp
careful sublation of the connective and adipose morphology and mucous membrane of the gall-
tissues should begin from the region nearest to the bladder must be examined. In the event of a sus-
gallbladder. The sublation of adipose tissues pected malignancy, an emergent frozen section
proximal to Calot’s triangle would expose the cys- procedure must be performed.
tic duct. The cystic duct is usually exposed from
the right side of the patient such that the course of
the cystic artery can be identified on the left side. 30.2.2 Extended Cholecystectomy
However, in rare cases, the cystic artery may run (Lymphadenectomy)
along the cystic duct or exist on its right side,
which should be considered during the surgery. Here, we discuss lymphadenectomy for patients
Following exposure, the cystic duct should be with early-stage gallbladder cancer (T1b or
cut after ligation using a laparoscopic clip. The higher). At present, there is no consensus on the
clip should not be placed too close to the com- range of lymph node dissection in patients with
mon bile duct or while causing excessive retrac- early-stage gallbladder cancer. The seventh edi-
tion of the gallbladder, which could lead to tion of the AJCC defined lymph nodes around
combined ligation of a part of the common bile hepatoduodenal ligaments, such as cystic duct,
duct. Although this phenomenon is uncommon in common bile duct, hepatic artery, and hepatic
patients with gallbladder polyps, gallstones may portal vein lymph nodes, as group 1 nodes (N1),
move into the cystic duct in some patients, while those around the pancreaticoduodenal, lap-
thereby causing severe inflammation of the gall- arotid artery, mesenteric artery, main artery, and
bladder, in turn leading to difficulty in ligating vena cava areas were defined as group 2 nodes
the duct. In such cases, the insertion of a thread or (N2). Metastasis in N2 is interpreted as distant
the use of loops enables ligation of the cystic lymph node metastasis, leading to a classification
duct. The gallbladder can be moved more easily of Stage 4 (IVB) cancer according to the TNM
after cutting the cystic duct, as doing so separates staging. As long-term survival cannot be expected
it from the common bile duct, thus facilitating in such cases, lymph node dissection is not gen-
ligation of the cystic artery. However, prior to erally recommended. However, the author
ligation, it is important to evaluate whether the includes the lymph nodes around the main artery
cystic artery enters the gallbladder. It must be during dissection in all patients with stage T1b or
noted that 50% of the patients only have one cys- higher gallbladder cancer. There is no consensus
tic artery, whereas the remaining 50% often have regarding the minimum or appropriate number of
two or three cystic arteries (Fig. 30.3c). lymph nodes that should be dissected to accu-
Upon completion of the procedure in the cys- rately determine the stage of cancer. The sixth
tic duct and artery, the gallbladder should be edition of the AJCC stated that at least three
sublated from the liver using a hook with the lymph nodes should be evaluated for metastasis
right hand (the second trocar) while appropri- to accurately determine the N stage, but this cri-
ately controlling retraction of the gallbladder terion was removed in the seventh edition.
with the left hand (the fourth trocar). The gall- While lymphadenectomy can be performed
bladder can be sublated from the liver without using both open and laparoscopic surgery, the
any perforation of the gallbladder wall only author prefers open surgery and employs the
when the thin membrane between the two struc- right subcostal incision. As lymphadenectomy
tures is exposed though proper retraction with for hepatoduodenal ligaments has been exten-
186 W.-J. Lee and M. J. Jung

sively discussed in the chapters on pancreatico- form the procedure while exercising caution and
duodenectomy and hilar cholangiocarcinoma, the utmost safety.
this chapter does not include a detailed discus-
sion of the same topic.
References
1. Blumgart LH. Surgery of the liver, biliary tract and
30.3 Conclusion pancreas. 5th ed. Philadelphia: Saunders Elsevier;
2013.
Laparoscopic cholecystectomy is a safe and 2. Fisher JE. Hepatobiliary and pancreatic surgery.
widely used surgical method in patients with Philadelphia: Lippincott Williams & Wilkins; 2013.
3. Lee SE, Jang JY, Kim SW. The surgical strategy for
gallbladder polyps and early-stage gallbladder treating T1 gallbladder cancer. Korean J Hepatobiliary
cancer, and it is a basic surgical technique for pancreat Surg. 2009;13(2):69–75.
hepatopancreaticobiliary surgeons. Although it is 4. Lee SE, Jang JY, Lim CS, et al. Systematic review on
relatively easier than those in the hepatopancre- the surgical treatment for T1 gallbladder cancer. World
J Gastroenterol. 2011;17(2):174–80.
aticobiliary field, laparoscopic cholecystectomy 5. Eckel F, Brunner T, Jelic S, et al. ESMO clinical prac-
can cause fatal complications if basic principles tice guidelines for diagnosis, treatment and follow-up.
are not followed; therefore, surgeons should per- Ann Oncol. 2011;22(6):40–4.
 Extended Cholecystectomy
(Wedge Resection) 31
Kim Wan-Joon and Kim Wan-Bae

Abstract 31.1 Surgical Procedure

Gallbladder cancer (GBC) is known to have a
poor prognosis, and curative radical resection The surgical procedure in extended cholecystec-
is the gold standard treatment. The factors tomy via open approach is as follows.
affecting the prognosis of GBC include depth
of tumor invasion and lymph node metastasis,
warranting proper hepatic resection and 31.1.1 Kocherization
lymphadenectomy.
Several studies have reported that T1 GBC In the newly published eighth edition of AJCC
has a good prognosis with simple cholecystec- TNM staging, the regional lymph nodes har-
tomy alone. Gallbladder cancers T2 and above vested during gallbladder cancer surgery were
are still referred to extended cholecystectomy #8, #12a, and #12p. To predict the progression
(Kim et al., Cancer Control. 27:2020). and prognosis of cancer, the author harvested the
This chapter describes extended cholecys- peri-aortic lymph node #16 after exposure to the
tectomy including liver wedge resection and aorta via kocherization (Fig. 31.1).
regional lymphadenectomy.

Keywords

Gallbladder cancer · Hepatic resection

Regional lymphadenectomy · Survival rate
Laparoscopic-extended cholecystectomy

Supplementary Information The online version con-

tains supplementary material available at https://doi.
org/10.1007/978-­981-­16-­1996-­0_31.

K. Wan-Joon (*) · K. Wan-Bae

Division of Hepato-Biliary-Pancreas Surgery,
Department of Surgery, Korea University Guro Fig. 31.1 Aortic lymph node dissection
Hospital, Korea University Medical College,
Seoul, South Korea

© Springer Nature Singapore Pte Ltd. 2023 187

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_31
188 K. Wan-Joon and K. Wan-Bae

31.1.2 Dissection of Cystic Duct

and Execution of Frozen
Biopsy of Cyst Duct Margin

The cystic duct is dissected from the bile duct

and divided in order to determine the need for
common bile duct (CBD) resection. Frozen
biopsy is performed after securing the cystic duct
margin from CBD side.
In principle, when cancerous lesion is detected
in the cystic duct margin, CBD resection must be
performed concomitantly.
After ligation and division of the cystic artery,
Fig. 31.2 Regional lymphadenectomy (yellow loop:
the gallbladder neck is separated from the surround- common bile duct, red loop: proper hepatic artery (upper
ing tissue to locate the gallbladder as far away as left); right gastric artery (lower left); splenic artery (right),
possible from the hepatoduodenal ligament. blue loop: portal vein (lower left); left gastric vein (upper
right)

31.1.3 Regional Lymphadenectomy However, if the falciform ligament is cut and

a part of the right coronary ligament and the
After adequate Kocherization, lymphadenectomy right triangular ligament is incised, the move-
is performed starting with the lymph node #13, ment of the liver becomes easier and the surgery
located between the common bile duct and the more convenient. There is no international con-
pancreatic head, extending over the liver along sensus, but the width of liver resection in wedge
the bile duct. The author harvests lymph nodes resection is generally recommended to be
#8, #12a, #12p, and #13 during lymphadenec- 2–3 cm.
tomy. Upon completion of lymph node harvest- In order to prevent cancer spreading, the gall-
ing at the right side of portal vein, the left edge of bladder and liver are excised en bloc. In order to
the hepatoduodenal ligament is opened, and the ensure sufficient liver resection, it is important to
lymph node is dissected until the left edge of the consider the extent of liver resection when you
portal vein is identified. first start wedge resection.
After confirming the left edge of portal vein, To ensure adequate width between the gall-
the lymph node that was previously dissected bladder and the liver resection site, the liver cut
along the right side of portal vein is rotated surface is made concave shape. To reduce the
behind the portal vein to perform lymph node en bleeding level during liver resection, the
bloc resection. During lymphadenectomy, the Pringle technique is used intermittently as
main vessels are tagged with a vessel loop to pre- needed. The author uses a method of blocking
vent injury (Fig. 31.2). the blood flow for 15 min and reperfusion for
5 min.
Because the terminal end of middle hepatic
31.1.4 Hepatic Resection vein (MHV), V5 vein, and Glissonean pedicle of
hepatic segments 4 and 5 appear during liver
Liver mobilization is not always necessary for resection, the above structures are carefully
hepatic wedge resection. ligated and separated (Fig. 31.3).
31 Extended Cholecystectomy (Wedge Resection) 189

approach. There is no consensus on the minimum

or appropriate number of harvested lymph nodes
required to determine the correct stage. According
to the eighth edition of AJCC, at least six lymph
node harvests are required to determine the
appropriate N stage. Appropriate laparoscopic-­
extended cholecystectomy can be performed
only by improving the proficiency of various
techniques such as liver resection, lymph node
dissection, and hepaticojejunostomy [3, 4].

Fig. 31.3 Images after extended cholecystectomy References

1. Choi KS, Choi SB, Park P, Kim WB, Choi SY. Clinical
characteristics of incidental or unsuspected gallblad-
31.2 Laparoscopic-Extended der cancers diagnosed during or after cholecystec-
Cholecystectomy tomy: a systematic review and meta-analysis. World
in Gallbladder Cancer J Gastroenterol. 2015;21(4):1315–23. https://doi.
org/10.3748/wjg.v21.i4.1315.
2. Han HS, Yoon YS, Agarwal AK, Belli G, Itano O,
Advances in laparoscopic surgery techniques Gumbs AA, et al. Laparoscopic surgery for gallblad-
have led to laparoscopic approaches targeting the der cancer: an expert consensus statement. Dig Surg.
biliary system. In the case of GBC, the focus of 2019;36(1):1–6. https://doi.org/10.1159/000486207.
3. Kim HS, Park JW, Kim H, Han Y, Kwon W, Kim SW,
laparoscopic-extended cholecystectomy is on
et al. Optimal surgical treatment in patients with T1b
patients at early-stage GBC (T1 or T2), inciden- gallbladder cancer: an international multicenter study.
tal GBC, and patients with strong suspicion of J Hepatobiliary Pancreat Sci. 2018;25(12):533–43.
negative cystic duct margin [1, 2]. https://doi.org/10.1002/jhbp.593.
4. Kim WJ, Lim TW, Park PJ, Choi SB, Kim
The caveats in the laparoscopic approach are
WB. Clinicopathological differences in T2 gall-
that the resection margin cannot be secured due bladder cancer according to tumor location. Cancer
to the unexpected tumor extension and inade- Control. 2020;27(1):1073274820915514. https://doi.
quate lymphadenectomy compared to the open org/10.1177/1073274820915514.
 Extended Cholecystectomy
(Including Segment IVb 32
and V Resection)

Sang-Jae Park

Abstract Keywords

Extended cholecystectomy in advanced gall- Cholecystectomy · Extended cholecystec-

bladder cancer (T2 or higher stage) entails tomy · Gallbladder cancer · Anatomic
liver resection, although the need for liver resection · Hepatectomy · Lymph node
resection in T1b GB cancer is disputed. The dissection
extent of liver resection is determined by the
location, gross type and extent of tumor, and
patient’s general and liver conditions. 32.1 Operation
Theoretically, extended cholecystectomy
including anatomic liver resection with seg- 32.1.1 Patient’s Position
ment IVb and V eliminates potential micro- and Diagnostic Laparoscopy
metastasis during venous drainage from (Fig. 32.1)
gallbladder cancer; however, no randomized
controlled studies have demonstrated the Supine position is usually recommended.
potential advantage. Two types of anatomic Diagnostic laparoscopy is recommended for
approach including separate ligation of portal the detection of metastasis missed in the preop-
triad (portal vein, hepatic artery, and bile duct) erative workup. I applied 2–3 trocars along the
and ligation of Glisson pedicles can be used. I midline and evaluated the liver surface, the great
prefer anatomic IVb + V resection via Glisson omentum, parietal peritoneum, serosa, and pelvic
approach. As the perfect anatomic IVb + V cavity in the counter-clockwise direction and
resection is technically complicated, I would used laparoscopic ultrasound to identify the liver
like to introduce modified anatomic IVb + V metastasis. The ascites are aspirated; otherwise,
resection, which is simple, safe, and fast. 500 mL of normal saline is into the abdominal
cavity and aspirated 5 min later for cytology
examination.

32.1.2 Incision
S.-J. Park (*)
Center for Liver and Pancreatobiliary Cancer,
National Cancer Center,
Various incisions including inverted L incision,
Goyang-Si, Gyeonggi-Do, South Korea Mercedes-Benz incision (ㅗ incision), or midline
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 191

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_32
192 S.-J. Park

incision can be used according to the operator’s 32.1.3 Examination of the Resection
preference. I prefer upper midline incision and Margin of Cystic Duct
occasionally extend to below umbilicus. Next, I
used the self-retractors and carefully evaluated First, the frozen biopsy of resection margin of
possible metastasis. cystic duct is examined, but common bile duct
resection is used in case of positive resection
margin of cystic duct or lymph node metastasis/
perineural invasion in hepatoduodenal ligament.
In this chapter, I will explain the case against
resection of common bile duct. The cystic artery
is resected after confirming the negative resection
margin of cystic duct.

32.1.4 Kocher Maneuver and Lymph

Node Dissection (Lymph Node
Group #13a, 8, 12) (Fig. 32.2)

I do Kocher maneuver for full mobilization of

duodenum to remove the LN group #13a from
pancreas head, followed by LN dissection upward
to hepatoduodenal ligament to remove #13a, 12,
8. Lymph node dissection mostly represents dis-
section of hepatic artery (common hepatic artery,
proper hepatic artery, and right and left hepatic
Fig. 32.1 Position of ports in diagnostic laparoscoy artery) from adjacent soft tissue. For this, I open

Fig. 32.2 Kocher

maneuver for lymph
node dissection of group
#13a, 8, 12
32 Extended Cholecystectomy (Including Segment IVb and V Resection) 193

the nerve plexus and incise along the upper part of 32.1.5 Liver Mobilization
hepatic artery and mobilize the right- and left-­
sided soft tissues to the right and the left of hepatic Liver mobilization is not necessary for anatomic
artery. I dissect and cut the right hepatic artery IVb + V resection; however, partial mobilization
from its origin. I sometimes dissect and cut the of falciform ligament, coronary ligament, and
gastroduodenal artery (GDA) from its origin for right triangular ligament can facilitate safe opera-
more complete lymph node dissection, which tion. No dissection of the right adrenal gland and
mostly does not harm the blood flow to liver, pan- IVC ligament is needed.
creas, and duodenum. But we should always be
very cautious in cutting gastroduodenal artery,
which may attenuate hepatic blood flow in very 32.1.6 Dissection of Glisson Pedicle
rare cases such as median arcuate ligament syn- (Right Glisson and Right
drome. Therefore, after transient clamping of Anterior Glisson Pedicle)
GDA, you should determine the hepatic blood for the Determination of Right
flow before cutting the GDA. Skeletalization of Resection Line (Fig. 32.3)
hepatic artery is followed by skeletalization
of portal vein using the same method of incision I perform conventional Glisson approach to dis-
of the soft tissue along the upper part of portal sect right Glisson pedicle and right anterior
vein and mobilization of the right-sided soft tissue Glisson pedicle. I clamp the right anterior
to the right side and the left-sided soft tissue to the Glisson pedicle and determine the line of the
left side of the portal vein. Finally, all the soft tis- discolored area. Ultrasound examination is per-
sue around pancreas head, hepatoduodenal liga- formed to evaluate the right and middle hepatic
ment, and common hepatic artery are moved from vein without injuring the right hepatic vein dur-
the right to the left side beneath the portal vein, ing the resection of segment V. The eventual
and removed from the right side of the portal vein. right resection line of segment IVb + V resec-

Fig. 32.3
Determination of right
resection line
194 S.-J. Park

tion is determined by the right side of discolored for segment IVa or IVb. A transverse line in the
segment V and also the right side of the right middle of segment IV is drawn to demarcate the
hepatic vein. unclear border between IVa and IV. This line
extends to the anterior section as the border of
segments V and VIII, which is the superior resec-
32.1.7 Determination of Left tion line.
and Superior Resection Lines During the resection of liver along the left
(Fig. 32.4) resection line, caution is needed during the
resection of liver along the right resection line
Liver resection can be easily initiated along the to avoid injury to the right hepatic vein. Next,
left resection line (between segment IVb and II/ the superior resection line is resected to a depth
III), which is the left resection line of segment of 2–3 cm, followed by dissection of the liver
IVb and V resection. IVb Glisson can be dis- toward the lower margin of anterior Glisson
sected and cut from its origin in the left Glisson pedicle. Multiple resection of right anterior
pedicle. Anatomy of segment IV Glisson is Glisson can be performed without injuring the
diverse and several Glisson pedicles meet at seg- segment VIII Glisson pedicle, followed by
ments IVa and IVb, and therefore, it is some- deeper liver resection between segments V and
times difficult to discriminate between the two VIII. When the resection is deeper and the
pedicles at these segments. Clamping each pedi- resected segment is retracted downward, the
cle can reveal whether each pedicle is intended border between segments V and VIII is clearer,

Fig. 32.4
Determination of left
and superior resection
lines
32 Extended Cholecystectomy (Including Segment IVb and V Resection) 195

which enables identification of the remnant Further Reading

Glisson pedicle V for safe ligation. The speci-
men can be removed. Kim SW, Suh KS. Hepatopancreatobiliary surgery. 3rd
ed; 2013.
Korean Society of Surgery. Atlas of Surgery.
2014;156:1278.
32.1.8 Management of Liver Cut Belghiti J, Jarnagin WR, DeMatteo RP, et al. Surgery of
Surface the liver, biliary tract and pancreas, 4th ed. 2006.

Management of liver cut surface is based on the

principles of conventional liver resection.
 Part V
Resection of Choledochal Cyst
 Open Resection of Chledochal Cyst
33
Kuk Hwan Kwon and Jin Ho Lee

Abstract 33.1 Introduction

Choledochal cyst is a relatively rare disease
and is predominantly found in Asian women. Choledochal cyst is a relatively rare disease con-
The treatment involves complete surgical stituting approximately 1% of all benign dis-
removal of the cyst, followed by bilioenteric eases of bile duct. Its incidence, although as high
anastomosis. Recent developments in mini- as 1:1000 in the Asian population, is only
mally invasive surgery and laparoscopic cho- 1:100 000 to 1:150 000 in the Western popula-
ledochal cyst excision are gradually increasing. tions. A preponderance of choledochoal cyst dis-
However, open choledochal cyst excision, ease is observed, especially in Asian women [1].
which has been traditionally performed, is the The etiology and pathogenesis of choledochal
most basic treatment for choledochal cyst. cysts are unknown, as the disease is attributed to
anomalous pancreaticobiliary duct union
Keywords (APBDU), but not in all adult cases [2]. The
causal relationship between choledochlal cyst
Adult · Choledochal cyst · Perioperative and biliary cancer has yet to be clearly identified.
management · Surgical management However, the causes include recurrent inflamma-
tion caused by the reflux of pancreatic enzymes
into bile duct or bile stasis, superinfection,
repeated cholangitis, or the conversion of bile
salt into carcinogens by chronic infections [3].
Supplementary Information The online version con-
tains supplementary material available at https://doi.
Clinically, eight types of classification (Fig. 33.1)
org/10.1007/978-­981-­16-­1996-­0_33. by Todani are used clinically and the treatment
methods vary according to the classification [4].
The surgical approaches used in patients under-
K. H. Kwon (*)
Department of Surgery, National Health Insurance
going primary resection include the following:
Service Ilsan Hospital, cholecystectomy, cyst excision, and Roux-en-Y
Goyang-si, Gyeonggi-do, South Korea hepaticojejunostomy for Todani types I and IVa;
J. H. Lee cyst excision and duodenal repair for Todani
Division of HepatoBilioPancreas Surgery, type III; and cholecystectomy and hepatectomy
Department of Surgery, National Health Insurance for Todani type V. In the present study, all type V
Service Ilsan Hospital,
Goyang-si, Gyeonggi-do, South Korea
patients carried intrahepatic lesions located in
e-mail: [email protected] the left liver. In order to preserve liver function

© Springer Nature Singapore Pte Ltd. 2023 199

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_33
200 K. H. Kwon and J. H. Lee

a b c

Fig. 33.1 (a) Choledochal cyst in a narrow sense (b) Segmental dilatation (c) Diffuse or cylindrical dilatation

and ensure accurate hepaticojejunostomy, only 33.2 Diagnosis

left hepatectomy was performed [5]. In this sec-
tion, we will discuss the choledochal cysts in Most of the choledochal cysts are found in chil-
adult cases, mainly seen in the field of hepatobi- dren, but approximately 20% of cases are diag-
liary pancreas, and especially focus on the most nosed in adults [6]. Choledochal cysts are found
common disease types (types I and IVb), show- in adults incidentally, but during the diagnosis of
ing similar clinical manifestations. complications such as cholangitis, pancreatitis,
33 Open Resection of Chledochal Cyst 201

bile duct stones, and malignant changes. It can be 33.4 Treatment

diagnosed via imaging tests such as abdominal
ultrasound, abdominal computed tomography, Surgical resection is the definitive treatment for
magnetic resonance cholangio-pancreatography choledochal cyst [4]. Surgery is recommended
(MRCP), and endoscopic retrograde cholangio-­ immediately after diagnosis rather than observa-
pancreatography (ERCP) and also confirms the tion because the incidence of biliary cancer
anatomical structure during surgery [7]. increases over time [8]. The surgical manage-
ment for adults with choledochal cyst is based on
the type of choledochal cyst and the presence of
33.3 Treatment Before Surgery associated hepatobiliary pathology. The general
principle is to completely excise the choledochal
The goal of preoperative treatment is to treat cyst, followed by mucosa-to-mucosa bilioenteric
inflammation in cholangitis, and to enable pre- anastomosis. After the resection of the chole-
cise imaging of the entire choledochal cyst dochal cyst, bilioenteric anastomosis can be
including the pancreaticobiliary duct union or the accompanied by Roux-en-Y hepaticojejunos-
intrahepatic bile duct, and to determine the bile tomy or choledochoduodenostomy. However, it
duct pathology associated with image. is relatively easy in the case of choledochoduode-
Cholangitis accompanied by choledochal cysts nostomy, but severe complications such as stump
warrants conservative treatments such as the syndrome may occur. In general, we follow the
usage of effective intravenous antibiotics. standard procedure, which is complete surgical
However, if the antibiotics are still not effective, resection of the choledochal cyst and the Roux-­
percutaneous or endoscopic choledochal cyst en-­Y hepaticojejunostomy. If it is not possible to
drainage is necessary to completely treat sepsis completely resect choledochal cyst, we may con-
caused by cholangitis before radical surgery. sider an alternative surgical option, which is
Imaging modalities such as MRCP or ERCP are Roux-en-Y cystojejunostomy after maximally
needed to avoid pancreatic duct damage during excising the choledochal cyst.
surgery, to determine the length of the narrow However, any stricture in the upper bile ducts
segment under the choledochal cyst precisely and warrants excision of the choledochal cyst includ-
ascertain the positional relationship between the ing the area with stricture, because lack of proper
main pancreatic duct and the choledochal cyst. treatment for bile duct stricture may result in
Also, before surgery, it is necessary to determine complications such as cholangitis, bile duct
whether the intrahepatic bile duct is stenotic or stone, and cancer. In the past, internal drainage
accompanied by choledochal cyst and biliary was performed, but the rate of cancer incidence
tract cancer. Stenosis of the intrahepatic bile duct in the case of internal drainage was up to 50% of
requires excision of the bile duct from the upper the rate in surgical patients, which was higher
stenotic segment. Concurrent choledochal cyst than in those without surgical treatment. In addi-
and biliary tract cancer warrant treatment plan tion, internal drainage induces anastomotic site
similar to cancer treatment. In particular, for stenosis, which leads to repeated cholangitis [9].
patients with repeated symptoms after surgery Accordingly, internal drainage was not per-
related to choledochal cyst in the past, it is neces- formed in recent years. Therefore, with a history
sary to determine the presence of strictures at the of internal drainage warrants radical surgery.
anastomotic site, bile duct stones, accompanying Minimally invasive surgeries, such as laparo-
malignant diseases, liver cirrhosis, and portal scopic surgery [10] or robotic surgery [11], have
hypertension. shown remarkable treatment results. In particu-
202 K. H. Kwon and J. H. Lee

lar, considering the nature of the disease, which is phy, (8) biliary cirrhosis, (9) portal hypertension,
frequent in young women, minimally invasive and (10) associated biliary malignancy. In gen-
surgery is expected to become popular in the eral, regardless of age, presenting symptoms,
future. However, additional surgical evaluation is biliary stones, prior surgery, or other secondary
needed to consider minimally invasive surgery as problems, surgery should include cholecystec-
a new standard. Therefore, the first step entails tomy and excision of extrahepatic cyst(s) [12].
investigation of the role of conventional open sur-
gery for the treatment of choledochal cysts. 1. If cholangitis is accompanied choledochal
cyst, conservative treatment using effective
intravenous antibiotics should be performed.
33.5 Treatment of Choledochal If there is no improvement in cholangitis with
Cysts Other Than Type antibiotic treatment alone, percutaneous or
I and IVb endoscopic choledochal cyst drainage should
be performed before surgery to completely
In the case of APBDU, bile duct resection is the treat sepsis caused by cholangitis, followed by
standard of treatment since the incidence of bile radical surgery.
duct cancer increases due to reflux of pancreatic 2. To avoid injury to the pancreatic ducts in the
fluid in the bile ducts. In the absence of APBDU, thinning area of pancreaticobiliary ductal
the treatment strategy is to perform surgery to junction, it is particularly important a thor-
prevent cholestasis. In the absence of conjuncti- ough knowledge of the anatomy between bile
val malformation, surgery to prevent cholestasis duct and ampulla of Vater is essential based
is required. In the case of type II, treatment can on preoperative direct or indirect cholangiog-
be performed simply by resecting the diverticu- raphy. Before surgery, CT or MRI should be
lum, which does not require excising the entire performed to investigate the extent of intrahe-
extrahepatic duct. In case of type III, treatment in patic involvement of choledochal cyst, and
most cases entails endoscopic sphincterectomy simultaneous hepatic resection is indicated if
except for large cysts warranting surgical resec- a wide range of choledochal cysts confined to
tion. In case of type IVa, choledochal cyst exci- one lobe are identified. Also, the possibility of
sion and hepaticojejunostomy should be widely accompanying malignant lesions should
performed. However, in case of intrahepatic always be borne in mind, and surgical plans
involvement of the cystic lesion with symptoms, should be established if there are cancerous
such as intrahepatic duct stone, cholangitis, liver findings such as weight loss, jaundice, tumor
cirrhosis, hepatic resection is indicated at the marker elevation, mass lesions, or mural nod-
same time as resection for type V. If liver resec- ules in the cyst.
tion is not possible due to extensive intrahepatic 3. If choledochal cyst is found during cholecys-
involvement of the cystic lesion, liver transplan- tectomy, cholangiography should be per-
tation should be considered. formed during the surgery to evaluate the
structure of the bile ducts.
4. Anatomy of the liver, bile duct, pancreas, and
33.6 Things to Know before portal vein should be clearly elucidated for
Surgery safe surgery. In particular, the following ana-
tomical knowledge is important and must be
According to Lipsett et al., factors to be consid- known.
ered when performing surgery on patients with (a) Hilar bile duct confluence is typically
biliary cystic disease include the following: (1) located in front of the right portal vein.
age, (2) presenting symptoms, (3) cyst type, (4) (b) Hepatic artery is located in the left poste-
associated biliary stones, (5) prior biliary surgery, rior of the choledochal cyst, and the left
(6) intrahepatic strictures, (7) atrophy/hypertro- and right branches are raised to the liver
33 Open Resection of Chledochal Cyst 203

in front of the portal vein. The right 2. Cholecystectomy is performed via top-down
hepatic artery is located primarily behind method, and the cystic artery is identified in
the choledochal cyst, where the gallblad- the infundibulum area by gallbladder trac-
der artery is initiated (Calot triangle). tion, followed by ligation and resection. If
(c) If the right hepatic artery originates from necessary, intraoperative cholangiograms are
the SMA, it is located behind the chole- performed or amylase and lipase concentra-
dochal cyst until it enters the Calot trian- tions in the choledochal cyst are measured,
gle and then the liver from the posterior and bile in the cyst is collected for microbial
lateral direction along the right side of the culture.
common bile duct. 3. Duodenal mobilization is performed via
(d) Usually, the portal vein is distorted in the Kocher maneuver.
hepatoduodenal ligament by the huge 4. The front of the choledochal cyst is evaluated
choledochal cyst, suggesting the need for by carefully dissecting the hepatoduodenal
care. ligament along the left side of the bile duct
(e) Inflammatory adhesion based on recur- and by incising the upper edge of the duode-
rent cholangitis and pancreatitis prior to num. The circumference of the choledochal
surgery should be evaluated depending on cyst is carefully encircled with a vascular
hepatic artery and portal vein damage due loop or umbilical tape, and then, the vascular
to inflammation around the choledochal loop or umbilical tape is pulled to expose the
cystitis during severe detachment, and it portal vein.
is important to evaluate the portal vein to 5. During the exfoliation of the portion of pan-
avoid damage. Lilly et al. suggested that creatic parenchyma, careful dissection is
in the case of severe pericystic inflamma- essential to avoid damage to the pancreatic
tion, the posterior side of the cyst wall duct. In addition, small blood vessels must
remains intact so as not to damage the be ligated during surgery to decrease the risk
portal vein and hepatic artery during of bleeding in the biliary plexus.
efforts such as cyst resection [13]. 6. When the bile duct suddenly narrows a few
(f) The distal end of CBD directly enters the mm away from the replaced area of the duc-
pancreatic inferior posterior and forms a tal confluence and the normal diameter of
short segment before entering the pancre- the bile duct is exposed, a 3–0 or 4–0 absorb-
atic parenchyma, or externally on the able suture is used to suture ligation and
pancreas in the posterior groove. resection.
(g) In particular, in order to avoid unexpected 7. Then, the bile duct sac is pulled upward and
bleeding and damage to the bile ducts, it carefully separated from the lower hepatic
is necessary to determine the relationship artery and portal vein before proceeding to
between the bile duct, the right hepatic the left and the right confluence of the liver.
artery, and the cystic artery, which show At this time, when the end of the bile duct sac
frequent variations. emerges, it is excised from the upper part of
the bile duct. In adults, cholangitis is fre-
quent, and repeated internal inflammation is
33.7 Surgical Technique difficult to eliminate from the posterior ves-
sels. In some cases, internal cyst dissection
1. The right subcostal incision method is the (Lilly surgery) is performed by excising
most frequently used method for abdominal either the anterior or the posterior part alone,
incision, and when the cyst is large, the mid- with residual posterior wall mucosa. Due to
line incision or partial chevron method the possibility of cancer, the Lilly surgery is
ensures adequate exposure. not performed widely.
204 K. H. Kwon and J. H. Lee

8. If malignancy is suspected, frozen biopsy is Even though bile duct cancers develop in up to
indicated. If malignancy is established, the 6% of patients undergoing surgery after chole-
surgical margin should be excised until neg- dochal cyst excision, the etiology of bile duct
ative, followed by radical lymph node cancer is attributed to remnant choledochal
dissection. cysts or a history of subclinical malignancy.
9. The transverse colon is tracted upward to Therefore, postoperative cancer incidence
evaluate the Treitz ligament, and the jejunum requires a re-evaluation of the current opera-
is prepared for Roux-en-Y hepaticojejunos- tion. Due to the possibility of anastomotic ste-
tomy. The end of the Roux limb is closed in nosis or bile duct cancer, all surgical patients
two layers and placed in the hepatic hilum to require ultrasound and liver function tests as
develop anastomosis by passing a window well as regular follow-up testing for tumor
through the transverse colon and then to the markers such as CA 19–9, CEA, and CA 125.
right of the middle colon artery.
10. Hepaticojejunostomy is performed via end-­
to-­side anastomosis. At this time, the bilioen- References
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 Laparoscopic and Robotic Excision
of Choledochal Cyst 34
Jin-Young Jang and Jae Seung Kang

Abstract 34.1 Introduction

Advances in laparoscopic surgery and tech-
nique have established laparoscopic excision Choledochal cysts are rare congenital dilatations
of the choledochal cyst as a common surgical of the biliary system and generally affect Asian
procedure. It reduces tissue injury, facilitates population [1]. The clinical presentation of a cho-
precise dissection and anastomosis, and leads ledochal cyst varies with age [2]. In children, the
to better cosmetic outcomes than open sur- main symptoms include the presence of a mass,
gery. Recently, robotic surgical systems have jaundice, and perforation. However, with aging,
been introduced for the excision of the chole- the manifestations of choledochal cyst can
dochal cyst. We introduce the surgical proce- include stones, pancreatitis, and biliary tract can-
dures for laparoscopic and robotic excision of cer. Recently, asymptomatic choledochal cysts
the choledochal cyst and provide tips and pre- have been detected more frequently because of
cautions for preoperative evaluation, surgical routine health checkups [3]. Although they are
skills, and postoperative management. known to be benign, they must be surgically
resected to prevent the risk of choledocholithia-
Keyword sis, cholangitis, pancreatitis, and biliary malig-
nancy. In the absence of resection, there is a
Choledochal cyst · Laparoscopy · Robotic lifetime risk of malignancies such as cholangio-
surgical procedure · Minimally invasive carcinoma and gallbladder cancer [4, 5].
surgical procedure Advances in laparoscopic surgery and instru-
mentation have resulted in clinical application in
a variety of hepato-pancreato-biliary surgeries.
Laparoscopic approaches provide magnified sur-
gical views, allowing precise dissection and
Supplementary Information The online version con- anastomosis, reduced tissue injury, and better
tains supplementary material available at https://doi. cosmetic outcomes. However, the indications for
org/10.1007/978-­981-­16-­1996-­0_34.
laparoscopic surgery should be considered care-
fully, based on patients’ safety and the need for
J.-Y. Jang (*) · J. S. Kang complete resection. Recently, robotic surgical
Department of Surgery and Cancer Research systems have been introduced and expanded to a
Institute, Seoul National University College of
Medicine, Seoul, South Korea
variety of surgeries [6, 7]. Robotic surgeries
e-mail: [email protected] facilitate wrist movement and three-dimensional

© Springer Nature Singapore Pte Ltd. 2023 207

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_34
208 J.-Y. Jang and J. S. Kang

vision and compensate for hand tremor and there-

fore can be performed with more precise control
than laparoscopic surgery.
Although there are no absolute contraindica-
tions, a few relative contraindications for laparo-
scopic excision of the choledochal cyst include
11/12 mm port
the following: the possibility of combined liver
resection, common hepatic duct remnant too 5 mm port
small for anastomosis, severe inflammation
around the cyst, and suspicion of malignancy.
We elucidate the surgical procedures for mini-
mally invasive excision of a choledochal cyst
using a laparoscopic system, followed by the use
of robotic system. Fig. 34.1 Site and size of the trocars for laparoscopic
excision of the choledochal cyst [2]

34.2 Laparoscopic Excision

of Choledochal Cyst 34.2.3 Dissection of Calot’s Triangle
and Exposure of the Distal
34.2.1 Operating Room Setup: Margin of the Choledochal
Patient Position Cyst

The patient is placed in a supine position, in the To expose Calot’s triangle, the operator grasps
15° reverse Trendelenburg position and with a the infundibulum of the gallbladder (GB) and
slight right-up rotation. The surgeon and the pulls laterally. After dissection of the anterior and
­scopist stand to the left side of the patient, and the posterior peritoneal layers, the cystic duct and
first assistant stands on the right side. artery are exposed and the cystic artery ligated
using an endo-clip. From the cystic duct, the hep-
atoduodenal ligament is dissected along the right
34.2.2 Trocar Placement choledochal cyst margin, and the dissection
and Exposure extended along the supraduodenal margin. The
duodenum is retracted downward using an intes-
A 12-mm balloon trocar is inserted through an tinal grasper. The choledochal cyst is retracted
infra-umbilical site using an open access technique, upward, and the retroduodenal and intrapancre-
avoiding damage to intra-abdominal organs. A atic portion of the choledochal cyst is dissected
pneumoperitoneum is established, and a laparo- using a Harmonic Scalpel™ (Ethicon Endo-­
scope is inserted through the trocar. The abdominal Surgery, Cincinnati, OH, USA) to ensure hemo-
cavity is explored and the operation site exposed. stasis of the epicholedochal venous plexus
Another 12-mm trocar is inserted just below the (Fig. 34.2).
right side of the xiphoid process, a 5-mm trocar at
the mid-clavicular subcostal site, and another
5-mm trocar in the axillary line (Fig. 34.1).
34 Laparoscopic and Robotic Excision of Choledochal Cyst 209

Fig. 34.3 Distal stump ligated using a vascular Endo-GIA

Fig. 34.2 Dissection of intrapancreatic transition point
(arrow) of the choledochal cyst

34.2.4 Excision of the Choledochal

Cysts

The distal stump is ligated and transected with a

45-mm vascular Endo-GIA once the transection
line of the choledochal cyst has been determined
(Covidien, Norwalk, CT, USA) (Fig. 34.3).
After pulling the distal portion of the chole-
dochal cyst upward, dissection is continued
along the medial and posterior margins of the
choledochal cyst until the common hepatic duct Fig. 34.4 Transection of the choledochal cyst at the
(CHD) is identified. The choledochal cyst is hilum level
then transected below the bifurcation with lapa-
roscopic scissors (Fig. 34.4), and the cystic duct
is then clipped and divided. The GB is left in its
fossa for liver traction during the hepaticojeju-
nostomy (HJ).

34.2.5 Roux-En-Y Reconstruction

After excision of the choledochal cyst, a retro-

colic Roux-en-Y HJ is made. A small hole is cre-
ated in the mesentery of the jejunum 50 cm distal
to the ligament of Treitz using the Harmonic scal-
pel for the passage of the Endo-GIA (Fig. 34.5).
After transection of the jejunum using the Endo-­ Fig. 34.5 Transection of the jejunum for a Roux-en-Y
GIA, the jejunum mesentery is divided with an loop 50 cm distal to the ligament of Treitz
endo-clip and LigaSure™ (Medtronic,
Minneapolis, MN, USA). A hole is made at the behind the colon. LapLoop (Sejong Medical Co.,
meso-colon lateral to the duodenum, and the Paju, Korea) facilitates laparoscopic suturing
Roux limb is brought up to the hepatic hilum because it carries a premade surgical knot and a
210 J.-Y. Jang and J. S. Kang

Fig. 34.6 Suture fixation of Roux limb to the meso-

colon

Fig. 34.7 Intracorporeal suture for the posterior aspect of

knot pusher function. Interrupted sutures are used the hepaticojejunostomy
to fix the Roux limb and fill the meso-colon hole
to prevent internal hernia (Fig. 34.6).
34.2.8 Tips and Comments

34.2.6 Hepaticojejunostomy Since the bile duct anatomy is complex and may
show abnormalities other than the cyst, such as
After approximation of the jejunum and hepatic anomalous pancreatic-bile duct union, it is
duct, a small incision is made in the anti-­ important to evaluate the precise anatomical rela-
mesenteric side of the jejunum for an end-to-side tionship between the cyst and other important
HJ. After stay sutures are inserted on both sides structures such as pancreatic duct, portal vein,
of the anastomosis, the posterior aspect of the HJ and hepatic artery. Because the operator only
is secured via interrupted sutures (Fig. 34.7), and along the caudal to cephalic direction using the
the anterior aspect is then sutured similarly. The laparoscope, it is difficult to identify accurately
GB is then dissected free, and a laparoscopic the pancreatic duct during dissection near the
endobag is inserted through the umbilical port suprapancreatic part. Therefore, preoperative
trocar, and the specimens are placed in the bag. computed tomography (CT), endoscopic retro-
grade cholangiopancreatography, or magnetic
resonance cholangiopancreatography are needed
34.2.7 Extracorporeal to determine the extent of surgery and prevent
Jejunojejunostomy damage to the pancreatic duct, portal vein, or
and Specimen Retrieval hepatic artery. Intraoperative choledochoscopy
facilitates identification and evaluation of the
A 1 cm extension of incision to the umbilicus is pancreatic and intrahepatic ducts.
enough to pull through the jejunum and endobag To ensure patient’s quality of life, it is impor-
and perform jejunojejunostomy (JJ). At 60 cm tant to determine the appropriate proximal tran-
distal to the HJ site, the Roux limb is fixed to the section line and perform safe HJ. Dilation of the
transected upper limb via laparoscopic sutures remnant CHD seldom leads to anastomotic stric-
twice to prevent twisting. After extraction of the tures. However, if the diameter of the remnant
endobag, Roux limb and upper limb are pulled CHD is very small, surgical complications such
through the umbilicus site, followed by side-to-­ as strictures or bile leakage can occur. If the cho-
side JJ manually or via Endo-GIA. One Jackson-­ ledochal cyst is not complicated by a malignant
Pratt drain is inserted through the 5 mm port in lesion, it is better to leave some portion of the
the axillary line and located behind the HJ site. proximal cyst for safe and easy anastomosis,
The wounds are then closed. rather than perform a radically complete exci-
34 Laparoscopic and Robotic Excision of Choledochal Cyst 211

section, and tactile sense. Robotic surgery

ensures dexterity, precision, and stability of com-
plex techniques, including intracorporeal sutures,
which are especially important in HJ after cyst
excision [3]. Accordingly, laparoscopic dissec-
tion and robotic anastomosis are preferred.
However, pure robotic surgery (both dissection
and anastomosis) can be selected if surgeons pre-
fer, or if competent surgical assistants are not
available.
We introduce below a hybrid technique of
Fig. 34.8 Remnant upper part of the cystic duct for laparoscopic excision of the choledochal cyst
anastomosis
combined with robotic HJ anastomosis. The da
Vinci Surgical System (Intuitive Surgical,
sion. Also, the upper part of the cystic duct can be Sunnyvale, CA, USA) is used.
used like a flap (Fig. 34.8), which along with
remnant CHD can be safely and effectively anas-
tomosed to the Roux limb. 34.3.1 Trocar Placement and Excision
of the Choledochal Cyst via
Laparoscopic Surgery
34.2.9 Postoperative Management
and Follow-Up of Patients Trocars are placed in a U-shape in the robotic
system (Fig. 34.9). A 12-mm balloon trocar is
The patient usually starts a liquid diet on postop- inserted 3 cm below the umbilicus. Three 8 mm
erative day 1. The closed drain tube is removed if robotic trocars are inserted in the right axilla,
a CT scan on postoperative day 4 shows no right mid-clavicular, and left axillary line. A
abnormal fluid collection. The patient visits the 12 mm trocar for the assistant is inserted on the
outpatient department 2 weeks after discharge mid-clavicular line. A 5 mm trocar is inserted in
and again at 3 months. In case of no complica- the epigastrium for traction of the liver during
tions, the patient can be followed up every laparoscopic dissection. Dissection and excision
12–18 months. Appropriate monitoring includes
a routine complete blood count, liver function
tests, and measurement of tumor markers (includ-
ing carcinoembryonic antigen and carbohydrate-­
associated antigen 19–9). CT or MRI is performed
to evaluate signs of complications such as pan-
creatitis, cholangitis, choledocholithiasis, or
malignancy.

34.3 Robotic Excision

of the Choledochal Cyst

Surgeons can perform dissection using both the

laparoscopic and the robotic platforms.
Laparoscopic surgery allows quick and easy han-
dling of various instruments, a wider range of Fig. 34.9 Port placement in robotic choledochal cyst
motion, a wider surgical field of view during dis- excision [3]
212 J.-Y. Jang and J. S. Kang

of the choledochal cyst are similar to the laparo-

scopic procedure. The Harmonic scalpel is used
for dissection and hemostasis around the cyst,
and the Endo-GIA is used to transect the distal
part of the cyst and jejunal limb for a Roux-en-Y
reconstruction. The laparoscopic instruments are
removed and the robotic surgical system is
docked after retrocolic fixation of the Roux limb
with premade suture loops (LapLoop) and prepa-
ration for extracorporeal performance of a JJ as
described in paragraph 34.2.7 above.

34.3.2 Robotic HJ Anastomosis Fig. 34.11 Closed drain placed behind the HJ site

Vicryl 4–0 interrupted sutures with 1–2 mm

spacing are placed at the posterior and anterior
34.4 Short-Term and Long-Term
walls (Fig. 34.10). If the remnant CHD is large
Outcomes
enough, barbed suture material (V-Loc™,
Medtronic, MN, USA) is inserted continuously
One study reported comparisons of short-term and
at the posterior wall, and vicryl 4–0 interrupted
long-term outcomes between pure-­laparoscopic and
sutures are inserted in the anterior wall. A
hybrid robotic groups [3]. The mean operative time
Jackson-Pratt drain tube is placed behind the HJ
was significantly shorter in the laparoscopic group
site (Fig. 34.11), and the robotic system is
than in the hybrid robotic group (181.31 ± 43.06 min
removed from the surgical field. After a 3 cm
vs. 247.94 ± 54.14 min, p < 0.05). The mean esti-
extension of the umbilical port site, the endobag
mated blood loss between the two groups was not
is extracted and JJ is performed extra-corpore-
significantly different (108.71 ± 15.53 mL vs.
ally as described earlier.
172.78 ± 117.46 mL, p = 0.097), as was the mean
postoperative hospital stay (7.33 ± 2.96 days vs.
6.22 ± 1.06 days, p = 0.128). None of the subjects
required open conversion.
Short-term surgical complications were
defined as complications occurring within
30 days of surgery. Although a total of 11 short-­
term complications (22.4%) were observed in the
laparoscopic group, no complications were
observed in the hybrid robotic group (Table 34.1).
Long-term surgical complications were observed
in seven patients (14.3%) in the pure-­laparoscopic
group and two patients (11.1%) in the hybrid
robotic group. Biliary tract-specific complica-
tions occurred more frequently in the pure-­
Fig. 34.10 Interrupted suturing with vicryl 4-0 on the laparoscopic group than in the hybrid robotic
posterior wall group (22.4% vs. 0.0%, p = 0.029).
34 Laparoscopic and Robotic Excision of Choledochal Cyst 213

Table 34.1 Surgical complications of pure-laparoscopic vs. hybrid robotic group [3]
Complications Pure-laparoscopic (n = 49) Hybrid robotic (n = 18) P value
Short-term 11 (22.4) 0 (0.0) 0.029
Bleeding 1 (2.0) 0 (0.0)
Fluid collection 1 (2.0) 0 (0.0)
Bile leakagea 7 (14.3) 0 (0.0) 0.176
Wound 1 (2.0) 0 (0.0)
Ileus 1 (2.0) 0 (0.0)
Long-term 7 (14.3) 2 (11.1) 0.999
Hepatic duct stonea 3 (6.1) 0 (0.0) 0.558
Hepaticojejunostomy stricturea 1 (2.0) 0 (0.0) 0.999
Fluid collection 0 (0.0) 1 (5.6)
Ileus 1 (2.0) 1 (5.6)
Biliary tract-specific 11 (22.4) 0 (0.0) 0.029
a
Biliary tract-specific complications. Values are presented as number (%)

34.5 Conclusion 3. Lee H, Kwon W, Han Y, Kim JR, Kim SW, Jang
JY. Comparison of surgical outcomes of intracorporeal
hepaticojejunostomy in the excision of choledochal
Minimally invasive excision of choledochal cysts using laparoscopic versus robot techniques.
cysts yields not only better cosmetic results but Ann Surg Treat Res. 2018;94(4):190–5. https://doi.
also superior functional recovery than open sur- org/10.4174/astr.2018.94.4.190.
4. Lee SE, Jang JY, Lee YJ, Choi DW, Lee WJ, Cho
gery. Therefore, this surgery is more common. BH, et al. Choledochal cyst and associated malig-
Robotic surgery is more precise and stable, and nant tumors in adults: a multicenter survey in South
associated with fewer rates of short-term and Korea. Arch Surg. 2011;146(10):1178–84. https://doi.
long-term complications than laparoscopic org/10.1001/archsurg.2011.243.
5. Sastry AV, Abbadessa B, Wayne MG, Steele JG,
surgery. Cooperman AM. What is the incidence of biliary car-
cinoma in choledochal cysts, when do they develop,
and how should it affect management? World J
References Surg. 2015;39(2):487–92. https://doi.org/10.1007/
s00268-­014-­2831-­5.
6. Jung M, Morel P, Buehler L, Buchs NC, Hagen
1. Wiseman K, Buczkowski AK, Chung SW, Francoeur
ME. Robotic general surgery: current practice,
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cysts in adults in an urban environment. Am J Surg.
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2. Jang JY, Kim SW, Han HS, Yoon YS, Han SS,
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org/10.1007/s00464-­005-­0565-­z.
 Part VI
Hilar Cholangiocarcinoma
 Extended Right Hepatectomy
and Caudate Lobectomy 35
Shin Hwang

Abstract 35.1 Indications

Perihilar cholangiocarcinoma is defined as
• Bismuth–Corlette IIIA cholangiocarcinoma
adenocarcinoma occurring at the hepatic
invading the right hepatic duct.
hilum. This tumor grows longitudinally along
• Complete resection of the right lobe and cau-
the bile duct and penetrates the bile duct wall.
date lobe is recommended to increase surgical
It invades the connective tissue along the bile
curability even in Bismuth–Corlette II type
duct. Therefore, curative resection requires en
bile duct cancer, where the tumor is limited to
bloc resection of the bile duct and surrounding
the hepatic duct without spreading to either
connective tissues, and concurrent resection
side of the left or right hepatic duct.
of the invaded vessels if needed.
• Although the perihilar bile duct cancer is
Bismuth-­ Corlette IV type, which infiltrates
Keywords
both left and right sides of the hepatic duct, it
Perihilar bile duct cancer · Gallbladder cancer is also applicable to tumor-negative resection
Hepatectomy · Post-hepatectomy hepatic of the left bile duct.
failure · Postoperative pancreatic leak
Complication · Abdominal drain
35.2 The Concept of Extended
Right Hepatectomy

The relationship between the bile ducts and the

surrounding blood vessels in the hepatic hilum
exhibits the following characteristics (Fig. 35.1).
Supplementary Information The online version con-
tains supplementary material available at https://doi. 1. Because the bile duct runs in an inclined
org/10.1007/978-­981-­16-­1996-­0_35. direction to the right side of the hepatoduode-
nal ligament, the branches of the left and the
right hepatic duct are located on the right side
S. Hwang (*)
Division of Hepatobiliary Surgery and Liver of the hepatic hilum. The left hepatic duct is
Transplantation, Department of Surgery, Asan longer, and thus, it can be resected with a lon-
Medical Center, University of Ulsan College of ger stump.
Medicine, Seoul, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 217

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_35
218 S. Hwang

Fig. 35.1 Standard

vasculature of the portal
vein. PHA = proper
hepatic artery, LHA =
left hepatic artery, MHA
= middle hepatic artery,
RHA = right hepatic
artery, Ap = right
posterior hepatic artery,
CBD = common bile
duct, B2 = segment II
bile duct, B3 = segment
III bile duct, B4 =
segment IV bile duct, Bp
= right posterior duct,
PV = main portal vein,
UP = umbilical portion
of the portal vein

2. The left hepatic artery is located on the left dal lobectomy are the preferred forms of radi-
side of the hepatoduodenal ligament and away cal surgery. In this procedure, since the
from the bile duct infiltrated with tumor. In volume of the liver that is normally resected is
contrast, in most cases, the right hepatic artery more than two-third of the volume of the total
reaches the right side of the common hepatic liver, it is essential to ensure adequate volume
duct while traversing the dorsal side of the of the remaining liver before surgery to pre-
common bile duct, and thus easily infiltrated vent liver failure. Therefore, if the right lobe is
with cancer. In addition, even if there is no not already atrophied sufficiently, preopera-
invasion, the right hepatic artery must be care- tive right portal vein embolization is per-
fully separated from the adjacent bile ducts formed to induce hypertrophy of the left lobe.
invaded by the tumor, and thus, the tumor is
inevitably over-manipulated in this process,
which can lead to the dissemination of cancer 35.3 Preoperative Evaluation
cells. and Management
3. Since most of the caudate lobe bile ducts are
infiltrated with cancer, resection of the cau- Preoperative evaluation is defined as evaluation
date lobe is essential for radical resection. of the degree of cancer progression (the extent of
4. When portal vein resection is required, the bile duct invasion, the presence or absence of
long transverse portion of the left portal vein vascular invasion and its site), liver function, and
easily ensures sufficient distance during rate of hepatic parenchymal resection.
resection and reconstruction compared to the Preoperative management is a biliary decompres-
right portal vein. For these reasons, except sion procedure and portal vein embolization.
when the occupied site of hepatic bile duct
cancer is clearly dominant in the left hepatic 1. Preoperative evaluation
duct (Bismuth-Corlette IIIB type bile duct For curative surgery for cancer, the
cancer), (extended) right lobectomy and cau- achievement of tumor-negative resection mar-
35 Extended Right Hepatectomy and Caudate Lobectomy 219

gins is the most important goal. Magnetic is recommended to control cholangitis if pos-
resonance cholangio-pancreatography sible. Although a few cases of cancer cell
(MRCP), which was performed before spread at the PTBD tract have been reported,
decompression of the obstructed bile duct, it is reasonable to perform PTBD without hes-
provides important information by accurately itation if indicated. In some cases, endoscopic
revealing the extent of dilated bile ducts. retrograde biliary drainage (ERBD) is per-
Cholangiography according to endoscopic formed to ensure patient comfort before sur-
retrograde cholangiography (ERC) or percu- gery. However, it increases the risk of
taneous transhepatic biliary drainage (PTBD) ascending cholangitis, and thus, it should be
also shows the extent of tumor. The extent of avoided in patients scheduled for surgery.
tumor invasion outside the wall of the bile 4. Portal vein embolization
duct, such as invasion of the surrounding In perihilar bile duct cancer, the decrease
blood vessels, is evaluated via dynamic com- of hepatic functional reserve is accompanied
puted tomography (CT) and contrast MRI, by prior obstructive jaundice. Therefore, the
and the extent of invasion can be more accu- future remnant liver volume should remain at
rately identified in the 3-dimensional images least 40% of the total liver volume. In cases of
of reconstruction. severe preoperative jaundice or deteriorated
2. Since the right lobe occupies more than two-­ liver function, and when minor future remnant
third of the total volume of the liver, including liver volume is expected, it is important to
the caudate lobe, preoperative volumetry via increase the safety of the operation by induc-
dynamic CT is used to calculate the parenchy- ing hypertrophy of the future remnant liver
mal resection rate. In general, since obstruc- via portal vein embolization. Within a few
tive jaundice is accompanied by perihilar bile days after performing the percutaneous right
duct cancer, the reliability of the indocyanine portal vein embolization, a dynamic CT is
green retention test for evaluating hepatic used to evaluate the status of portal vein
functional reserve is low. Based on the decom- embolization. In order to prevent rapid dete-
pression degree of obstructive jaundice, rioration in liver function after the portal vein
patient’s age, chronic hepatitis, combined embolization, right portal vein embolization
pancreatoduodenectomy, and the patient’s is recommended when the total bilirubin level
general condition, it is important to ensure is decreased to about 5–8 mg/dL. Doppler
that the estimated future remnant liver volume ultrasonography may be performed to estab-
is 40% or more of the total liver volume. lish the absence of residual blood flow in the
3. Biliary decompression procedures right portal vein several days after the portal
If there is jaundice before surgery, suffi- vein embolization procedure, but dynamic CT
cient biliary decompression is necessary to yields more accurate information. Dynamic
improve liver function and prevent cholangi- CT is performed at 1-week intervals to deter-
tis. When massive hepatic resection, includ- mine the degree of right liver atrophy and left
ing right hepatectomy, is scheduled, the target liver hypertrophy. Surgery is indicated when
reduction in total bilirubin is less than 2 mg/ the estimated future remnant liver is more
dL. Biliary decompression via endoscopic than 40% of the total liver volume and the
naso-biliary drainage (ENBD) is attempted total bilirubin value is less than 2 mg/dL. If
first, and PTBD can be used concurrently in the patient has to wait for a long time because
cases with a slow rate of biliary decompres- of inadequate biliary decompression, the
sion and uncontrolled cholangitis. ENBD can tumor progresses slowly even during the wait-
be performed on one or both sides. In perihilar ing period, so surgery is recommended within
bile duct cancer where the left and right bile 4 weeks after portal vein embolization if
ducts are separated, bilateral biliary drainage possible.
220 S. Hwang

5. Hepatic vein embolization bile duct and surrounding connective tissues and
If it is difficult to expect adequate levels of
the right lobe and caudate lobe are excised
right hepatic atrophy and left hepatic hyper- together.
trophy only with right portal vein emboliza- The actual surgical procedures are as follows:
tion, additional hepatic vein embolization can (1) dissection of the bile duct and surrounding
be performed to block the right hepatic vein connective tissue in the hepatoduodenal liga-
and the inferior hepatic vein. When both the ment;(2) skeletonization of the left and middle
portal vein and hepatic venous blood flow of arteries and the left portal vein to the intended
the right liver are blocked, the amount of site of the left hepatic duct transection; (3) mobi-
blood flowing to the right posterior region is lization and dissection of the right lobe and cau-
decreased significantly, resulting in effectivedal lobes; (4) hepatic parenchymal transection;
induction of parenchymal atrophy of the right and (6) transection of the left hepatic duct and
liver and efficient hypertrophy of the left liver.
bile duct reconstruction (Fig. 35.2).
The hepatic parenchymal transection plane
differs depending on the extent of hepatic resec-
35.4 Intraoperative Management tion. Extended right lobectomy can be performed
of Biliary Decompression to completely remove the middle hepatic vein if
Tubes the left liver is large enough and carries a fissural
vein between the middle and left hepatic veins. If
A bile drainage tube (PTBD or ENBD) is inserted the left liver is not large enough or the risk of
because most of the patients with perihilar bile surgery is high, the ventral half of the middle
duct cancer show accompanying obstructive hepatic vein is removed and the dorsal half of the
jaundice. Aggressive curative surgery is a time-­ middle hepatic vein is preserved in order to con-
consuming operation, and inappropriate bile serve some of the segment IV parenchyma. Such
drainage during surgery adversely affects the extensive surgical resection is preferred to ensure
postoperative course, so management of the high surgical safety.
drainage tube is important. Before starting the
surgery, the PTBD drainage tube should be 1. Incision and surgical field of view
disconnected, and the end of the PTBD tube
­ The surgical field of view is secured via a
should be wrapped with surgical gloves, for use mirrored-L-shaped, right horizontal incision
as a temporary drainage bag during surgery. The
ENBD tube remains intact until the common bile
duct is transected.

35.5 Operative Procedures

After dissecting the common bile duct within the

hepatoduodenal ligament and transecting it at the
upper edge of the pancreas, the bile duct and sur-
rounding connective tissues, lymph nodes are
resected, followed by transection of the right
hepatic artery and the right portal vein. By skel-
etonizing the main portal vein and hepatic arter-
ies, all connective tissues that may carry cancer
cells are removed leading to the planned site of
the left hepatic duct transection in the liver. The Fig. 35.2 Extent of hepatic resection and skeletonization
parenchymal transection leads to this site, and the of the hepatoduodenal ligament
35 Extended Right Hepatectomy and Caudate Lobectomy 221

after exploring for ascites, peritoneal dissemi- along the pancreatic parenchyma until it
nation, and liver metastasis by opening an reaches the pancreatic upper margin. The pos-
upper median incision from the xyphoid pro- terior-superior pancreaticoduodenal artery is
cess to the upper part of the umbilicus. A hori- proximal to the branch of the gastroduodenal
zontal incision on the left side is usually not artery from the common hepatic artery, and
required although the extent of incision varies the posterior-­ superior pancreaticoduodenal
depending on the type of retractors. A better vein enters the portal vein from the dorsal
surgical field of view can be secured by resect- side. While hooking and pulling the lower
ing the xiphoid process. The PTBD tube on common bile duct with a vascular rubber
the left side is released by cutting the fixation loop, the common bile duct is transected at the
suture, thereby pushing the tube into the upper edge of the pancreas warranting intra-
abdominal cavity and reconnecting the surgi- operative frozen-section biopsy with the end
cal rubber gloves, to continuously drain the of the bile duct resection margin (Fig. 35.3). It
bile into the glove during surgery. If the recon- is essential to ensure the absence of free tumor
struction of the biliary tract is incomplete or mass or blood clots in the residual bile duct by
there is a risk of post-hepatectomy liver fail- strongly injecting normal saline using a ball-
ure, the PTBD tube on the left side is left tip syringe into the residual bile duct in the
uncut because PTBD can be maintained after pancreas. It is safer to suture the end of the
surgery. The lesser omentum is opened to bile duct in the pancreas continuously with a
observe whether the cancer has infiltrated the 5–0 non-absorbable monofilament rather than
peritoneum and observe the status of lymph suture ligation.
node metastasis. The falciform ligament is cut If the end of the bile duct is tumor-positive,
to expose the inferior vena cava inlet of the the distal bile duct is further excavated into
major hepatic veins. After ligating the round the pancreas by 1–3 cm to secure the maxi-
ligament to secure the visual field of view of mum marginal distance. It is transected, and a
the liver, the suture material is pulled and frozen-section biopsy is repeated. Excavation
fixed with a towel clamp over the retractor. of the pancreatic parenchyma increases the
2. Cholecystectomy and dissection and transec- risk of pancreatic leakage after surgery, so the
tion of the extrahepatic bile duct detached pancreatic tissues must be carefully
If cholecystectomy is not performed first, it sutured (Fig. 35.4).
is difficult to secure the field of view. 3. Skeletonization of blood vessels in the hepa-
Therefore, unless there is extensive tumor toduodenal ligament
infiltration in the cystic duct, retrograde cho- Once the common bile duct is cut and
lecystectomy is performed first. Subsequently, pulled cephalad, the portal vein and the hepatic
while touching the right hepatic artery, the artery are well exposed, and the surgical field
connective tissue of the hepatoduodenal liga- of view is secured. The periportal lymph nodes
ment is removed bit by bit to expose the right are dissected to simplify the vascular struc-
hepatic artery and the portal vein. The dissec- tures of the hepatic hilum, followed by the
tion is continued towards the pancreas after skeletonization of the hepatic arteries in the
grasping the common bile duct. hepatoduodenal ligament. Starting from the
The duodenum is mobilized by Kocher’s right hepatic artery or gastroduodenal artery,
maneuver, and the pancreatic capsule and sur- the periarterial neural plexus is carefully dis-
rounding tissues are dissected to expose the sected to expose the entire length of the hepatic
pancreatic parenchyma in the posterior part of artery leading to the right hepatic artery, mid-
the pancreas, and the lymph node No. 13 is dle artery, left hepatic artery, proper hepatic
then removed. The posterior-superior artery, common hepatic artery, and gastroduo-
pancreaticoduodenal artery and vein is
­ denal artery. At this time, if any of the lymph
exposed and dissection continues cephalad nodes around the hepatic artery are enlarged, a
222 S. Hwang

Fig. 35.3 Transection of the distal bile duct within the pancreas. CBD = common bile duct, RHD = right hepatic duct,
LHD = left hepatic duct, PV = portal vein, PHA = proper hepatic artery, LHA = left hepatic artery

Fig. 35.4 Extended bile duct resection performed by deep excavation into the pancreas
35 Extended Right Hepatectomy and Caudate Lobectomy 223

frozen-section biopsy is performed. In case of

a positive tumor, the periarterial neural plexus
is removed thoroughly, without damaging the
adventitia of the hepatic artery, since there is a
risk of developing pseudoaneurysm in the
future if the periarterial neural plexus is
removed excessively. Excessive use of electro-
surgery around the hepatic artery may induce
blood vessel damage, suggesting the need for
meticulous mechanical dissection. Although it
is convenient to hang with a vascular rubber
loop to traction the isolated artery, care should Fig. 35.6 Dissection of the left portal vein
be taken because excessive traction can cause
vascular damage. 2–3 caudate portal vein branches attached to
4. Transection of the right hepatic artery and the left portal vein are cut and ligated
exposure of the portal system (Fig. 35.6).
The right hepatic artery is cut and ligated, 5. Mobilization of the right lobe and caudate
and the surrounding connective tissues includ- lobe
ing lymph nodes and the common bile duct If the right portal vein is well exposed and
are lifted to the right and pulled. The main easily cut, it must be transected immediately. If
portal vein is pulled with a vascular rubber its detachment is difficult due to adhesion, the
loop to the right and the proper hepatic artery right portal blood flow is blocked with bulldog
to the left, followed by dissection of the clamps, and the right liver is mobilized. At this
hepatic artery and the connective tissues stage, both the arterial and portal blood flow to
around the portal vein along the longitudinal the right liver are blocked, so the surface of the
axis to expose the left and right portal branches right liver exhibits ischemic color change. The
(Fig. 35.5). right coronary ligament, right triangular liga-
The transverse portion of the left portal ment, and hepatorenal ligament are cut via
vein is dissected to sufficiently expose the left electrosurgery and the inferior vena cava is
portal vein branch. At this time, since the exposed by releasing the liver and the right
dilated bile duct often adheres to the left por- adrenal gland. More than 10 short hepatic veins
tal vein wall due to cholangitis, no portal infil- that drain the caudate lobe between the liver
tration should occur, which is confirmed by and the inferior vena cava are exposed and cut
dissecting only to the easily exposed area. The one by one from the caudal side. The vein
stumps at the inferior vena cava side are ligated
with sutures and those on the liver side are
ligated with metal clips. If the diameter of the
short hepatic vein is more than 3 mm, it is safe
to suture continuously with 5–0 Prolene.
Inferior vena cava dissection proceeds to the
left side, and the right inferior vena cava liga-
ment that exists outside the inferior vena cava
near the inlet of the right hepatic vein can be
seen. When this is cut, the proximal part of the
right hepatic vein is exposed. At this stage, a
tonsil forceps is inserted between the right
Fig. 35.5 Dissection of the portal vein branches at the hepatic vein and the middle vein, followed by
hepatic hilum
224 S. Hwang

insertion of a vascular rubber loop, nylon

string, or Penrose drain (Fig. 35.7).
If all the short hepatic veins on the left cau-
dal lobe (Spiegel lobe) are cut, the entire cau-
dal lobe can be completely mobilized. Since
the left inferior vena cava ligament is still
attached, the caudate lobe is not completely
mobilized, and the surgical field of view is not
good, so there is no need to forcefully cut the
left inferior vena cava ligament. The right
lobe and caudate lobe after liver mobilization
are firmly brought into the operator’s left hand
(Fig. 35.8). The right hepatic vein can be cut
Fig. 35.7 Hanging the lifting string between the right at this stage, but it is convenient not to cut it
hepatic vein and the middle vein during a hanging maneuver.
6. Transection of the hepatic parenchyma.
After cutting the right hepatic artery and
right portal vein, the hepatic parenchyma is
transected along the Cantlie line, which
demarcates the discolored right lobe from the
left lobe (Fig. 35.9).
The transection plane of the liver differs
depending on the location of cut and uncut
ventral portions of the segment IV. The main
features of the hepatic parenchymal transec-
tion are as follows: (1) preservation of the
middle hepatic vein and exposure of its right
wall, (2) total resection of the right lobe and
Fig. 35.8 Mobilization of the left liver

a b

Fig. 35.9 Determination of the hepatic transection plane with (a) or without (b) concurrent resection of the ventral
segment IV parenchyma
35 Extended Right Hepatectomy and Caudate Lobectomy 225

caudate lobe, (3) excision of the left hepatic draining segment V is located and cut to guide
duct as far as possible at the location when the along the path to reach the main trunk of the
hepatic transection is almost complete, and at middle hepatic vein. Exposing the right wall
this time, the caudal lobe duct is completely of the middle hepatic vein at the hepatic tran-
within the extent of resection. (4) Since the section plane reduces bleeding during surgery.
left hepatic duct enters the back side of the In case of middle hepatic vein injury, the
portal vein, a concurrent resection of the ven- bleeding point is gently pressed to stop bleed-
tral part of the segment IV ensures better vis- ing, and accurately identify the origin of
ibility for biliary reconstruction. bleeding, for hemostasis with a 6–0 Prolene
If the size of the segment IV is larger or suture if it is uncontrolled.
comparable to that of the left lateral section in While exposing the middle hepatic vein
preoperative volumetry CT, additional resec- longitudinally, along the inferior vena cava
tion of the ventral segment IV parenchyma inlet cephalad, the left caudate lobe can be
may trigger post-hepatectomy hepatic failure found to the right when the Arantius canal is
due to insufficient volume of the remnant cut at the site where the Arantius canal is con-
liver, so a careful approach is required. For nected near the junction of the inferior vena
further resection of ventral segment IV, a few cava and the left hepatic vein (Fig. 35.10).
small portal branches from the portal vein to The hanging method for hepatic transec-
the ventral segment IV should be cut to expose tion not only reduces bleeding from the
the right wall of the umbilical portion of the hepatic veins, but also prevents the risk of
left portal vein. At this time, it is important to misdirection of the hepatic parenchymal tran-
preserve the portal vein branches into the dor- section (Fig. 35.11). In the deeper part of the
sal segment IV (Fig. 35.9a). When the ventral
segment IV is not excised, the hepatic transec-
tion proceeds upwards and backward along
the Cantlie line, but in the vicinity of the
hepatic hilum, it is safe to prevent cancer infil-
tration into the hepatic parenchyma about
10 mm away from the hepatic hilar plate
(Fig. 35.9b). Therefore, only a small part of
ventral segment IV parenchyma is excised
together with the right lobe, and the actual
transection plane of ventral segment IV ­differs
in each case according to the degree of bile
duct infiltration. There is no need to com- Fig. 35.10 Hepatic transection plane
pletely remove the ventral segment IV paren-
chyma in all cases.
The hepatic parenchymal transection is
performed by holding the left hepatic artery
and the left portal vein with bulldog clamps;
thus, the blood inflow to the liver is blocked
(Pringle maneuver). The blood flow is repeat-
edly blocked by 15 min of blockade and 5 min
of release. Bleeding hemorrhage during the
parenchymal transection usually involves the
branches of middle hepatic vein. Therefore, a
vein branch from the beginning of the hepatic
parenchymal transection near the gallbladder Fig. 35.11 Hanging method via loop lifting
226 S. Hwang

hepatic transection plane after the main trunk Since the end of the transected left hepatic
of the middle hepatic vein is exposed, upward duct is shorter than before cutting, it is recom-
lifting of the hanging string opens the hepatic mended to leave 2–3 mm of bile duct resection
transection plane wide and improves the view margin on the remaining side to facilitate biliary
of the transection to easily control the bleed- reconstruction. A frozen-section biopsy with the
ing from the hepatic transection plane. The end of the bile duct can be used to confirm
left caudate lobe is pulled to the right, which whether the tumor is negative, and the bleeding at
is also useful in locating the direction of the end of the left hepatic duct is sutured with 6–0
transection. Prolene. If the left hepatic duct resection margin
7. Transection of the left hepatic duct and biliary is tumor-positive, if possible, the end of the left
reconstruction. hepatic duct is cut a little further and a
The last step of bile duct transection ­frozen-­section biopsy is repeated. The resected
involves transection of the left hepatic duct on left hepatic duct is exposed via 2 to 3 openings
the right side of the umbilical portion of the (Fig. 35.13). Usually, the most ventral side is seg-
left portal vein. The left caudal lobe Glisson ment II duct (B2) and the most ventral side is seg-
branches should be resected at the left hepatic ment IV duct (B4), and most of them are cut into
duct. Therefore, the right hepatic duct is two openings, B4 and segment II + III duct
pulled to the right and the bile duct is gently (B2 + 3) (Fig. 35.14).
cut with sharp surgical scissors to ensure a When a single Glissonean sheath carries 2–3
safe distance of 5–10 mm without tumor inva- bile duct openings and are connected by fibrous
sion (Fig. 35.12). connective tissues, each opening drains into a

Fig. 35.13 Three left hepatic duct openings within a

Fig. 35.12 Transection of the left bile duct single connective tissue sheath

Fig. 35.14 Types of left hepatic duct opening that are cut according to anatomical variations
35 Extended Right Hepatectomy and Caudate Lobectomy 227

single bile duct with 6–0 Prolene or absorbable an external drainage tube using the PTBD tract
material, to facilitate bile duct-enteric anastomo- (Fig. 35.17).
sis (Fig. 35.15). The PTBD insertion site on the right side of
Prior to biliary reconstruction, a number of the abdominal wall is electrocauterized or coagu-
traction sutures are placed on the ventral wall of lated with an Argon laser to remove buried cancer
each opening at 1.5-mm intervals; thus, the lumen cells. When the PTBD tube is removed from the
of each bile duct can is clearly visible. A 50-cm-­ left side of the abdominal wall, the side of the
long jejunum loop is made for biliary-enteric abdominal wall is partially excised electrosurgi-
anastomosis. In case of independent anastomoses cally. The remaining liver-side hepatic paren-
of two bile duct openings, the distance between chyma is burned with Argon coagulation to
the anastomotic openings at the jejunum should reduce the risk of local recurrence following the
be more than threefold the distance between the spread of cancer cells.
bile duct openings to create a natural anastomosis
(Fig. 35.16).
Sutures are made of 5-0 to 6-0 Prolene or
absorbable material. Continuous or intermittent
sutures are used on the dorsal wall of the anasto-
mosis, and intermittent sutures ventrally. A short
stent over the anastomosis is inserted and secured
with an absorbable suture to allow escape later.
A residual left PTBD tube can be used to insert

Fig. 35.16 Separate reconstruction of two bile duct

openings

Fig. 35.15 Three bile duct openings molded to enable Fig. 35.17 Insertion of the internal and external biliary
single bile duct-enteric anastomosis drainage tubes. B2–4 denotes segment II–IV ducts
 Part VII
Extrahepatic Bile Duct Cancer
 Bile Duct Resection
36
Joo Seop Kim

Abstract indicated for patients with proximal bile duct

cancer. Segmental BDR is mainly indicated for
Segmental bile duct resection (BDR) is not a
mid-bile duct cancer. However, most cancers
routine procedure. This operation is mainly
show longitudinal growth along the duct [2–4],
indicated for middle bile duct cancer and
and securing safe proximal margin of 10 mm for
rarely for Bismuth type I and II hilar bile duct
the R0 resection is impossible [5]. The method is
cancer with papillary tumor or lesions less
indicated basically for the middle bile duct can-
than T2 stage. Segmental BDR is less invasive
cer, and the Bismuth type I and II hilar cholan-
than pancreatoduodenectomy or major hepatic
giocarcinoma with papillary tumor and lesions
resection. This procedure should be performed
less than T2.
when the resection margin is more than 10 mm
for R0 resection.
36.2 Preoperative Management
Keywords
and Evaluation
Segmental bile duct resection
Most patients present with jaundice following
biliary obstruction. The necessity of preoperative
36.1 Introduction biliary decompression is controversial and not
recommended universally for all jaundiced
Neoplasms of extrahepatic carcinoma are divided patients. The procedures of decompression are
into hilar (49%), middle (25%), distal (19%), and determined according to the severity of icterus
diffuse types (7%), according to location and cor- and concomitant cholangitis. The decompression
responding surgical treatment modalities [1]. methods are performed via transhepatic route:
Pancreatoduodenectomy is a standard surgical percutaneous transhepatic biliary drainage
option for distal bile duct cancer, and bile duct (PTBD) or endoscopic route; endoscopic naso-
resection with combined hepatic resection is biliary drainage (ENBD); or endoscopic retro-
grade biliary drainage (ERBD). The timing of
operation does not depend entirely on the level of
J. S. Kim (*) total bilirubin. The author has performed opera-
Department of Surgery, Hallym University Kangdong tion when the level of total bilirubin is decreased
Sacred Heart Hospital, Hallym University School of to 5 mg/dL.
Medicine, Seoul, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 231

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_36
232 J. S. Kim

36.3 Operative Method the management. Dissection around the common

hepatic artery is continued and the tributaries of
Author recommends an upper midline incision right gastric artery are exposed. Each artery is
with or without extension below the umbilicus encircled and lifted with a vessel loop to enable
for rapid and extensive results. As the upper the dissection and to avoid vascular injury. The
abdomen is opened, resectability is first deter- distal portion of the bile duct is identified and dis-
mined via palpation of the hepatoduodenal liga- sected. When the distance is greater than 10 mm
ment. The absence of hepatic, peritoneal, or between the upper border of pancreas and the
bulky nodal metastasis is confirmed. The need for main tumor, the bile duct is transected (Fig. 36.2).
aspiration cytology is determined by the presence Distal resection margin is sent to the pathology
of ascites in the abdominal cavity. The incision is laboratory for frozen examination. When the fro-
extended below the umbilicus when the resection zen examination is positive for carcinoma, the
is decided. Using a Kent-type retractor, the bilat- distal bile duct is dissected from the surrounding
eral costal arches are elevated. A self-retractor pancreatic tissue similar to the surgery for con-
can be used in the low parts of incision for a sta- genital choledochal cyst. The tumor shows an
ble and wide surgical view (Fig. 36.1). infiltrative growth within and outside the bile
The lesser sac is opened and the dissection of duct lumen, prompting suggestions for excava-
lymph nodes is initiated from the celiac axis. The tion type resection of pancreas parenchyma to
coronary vein is dissected and divided. The com- avoid pancreatoduodenectomy [6]. This opera-
mon hepatic artery is exposed along the upper tion is less invasive than classical pancreatoduo-
border of the pancreas and nodal dissection is denectomy and is indicated for elderly patients or
continued to the right side. At the duodenal pylo- patients with major comorbidities. However,
rus, the periduodenal arteries and veins are atypical resection of pancreas is not easy because
ligated and divided. After dissection of vessels, a CUSA or forceps fracture method is not practical
bilateral ligation is performed. Ligation of the like in hepatic resection. Also, the procedure is
duodenal side using hemostats should be avoided time-consuming. Hence, conversion to pancre-
to prevent injury to the duodenal wall. Wide atoduodenectomy is rather safe for low-risk
devascularization of the duodenum results in dis- patients with positive resection margins. The
colorization. Although the risk of ischemia is not duodenum is fully mobilized by Kocher maneu-
high, delayed gastric emptying occurs when the ver and lymph node # 13 is dissected. The ante-
vagal nerve is cut. The nasogastric tube facilitates rior border of hepatoduodenal ligament is incised.
The dissection of common hepatic artery is car-
ried upward and the origin of right gastric artery
is identified and divided. The portal vein is then
exposed. Lymph nodes #12a are dissected to the
left side, and lymph nodes #12b, 12p are cleared
to the right side with bile duct. The bifurcation of
right hepatic artery is met and encircled in a ves-
sel loop. Concomitant cholangitis complicates
the identification of the bifurcation of left and
right hepatic artery. In such cases, the level of
cystic duct is useful to identify the bifurcation
point, because both levels are approximately sim-
ilar in anatomic location. The middle hepatic
artery generally originates from the left hepatic
Fig. 36.1 Author prefers an upper midline incision with
arteries. The division of middle hepatic artery is
extension below the umbilicus. Using the Kent-type
retractor and the self-retractor, the costal arch is elevated sometimes carried out to facilitate nodal dissec-
and the optimal area of operation is exposed tion. After the skeletonization of hepatic arteries,
36 Bile Duct Resection 233

Fig. 36.2 Dissection of lymph nodes is started at the celiac axis and continued to the right side. The distal part of com-
mon bile duct is transected. Skeletonized portal vein and hepatic artery are obtained

Fig. 36.3 Right and left hepatic ducts are separately transected. The middle hepatic artery is ligated and cut to facilitate
the dissection of lymph nodes

the gallbladder is removed from fundus to neck. Finally, the resected bile duct and lymph nodes
The cystic duct is not divided and should be are removed as a whole. The distal margin of bile
included in the resected specimen. The upper- duct is closed continuously with 4-0 or 5-0
most border of the hepatoduodenal ligament is prolene. The jejunum is cut below the Treitz liga-
dissected from the hepatic hilum. The bile duct is ment. Choledocho- or hepatojejunostomy is per-
cut from 10 mm of the tumor and resected margin formed in Roux-en-Y fashion. When left and
is sent for pathology examination (Fig. 36.3). right bile ducts are separated, choledochoplasty
When the pathology is positive for the proximal is conducted to generate an orifice (Fig. 36.4).
margin, additional resection of 5 mm is done and The use of internal or external stent depends on
right and left bile ducts are separately obtained. If the surgeon’s preference. Author prefers 5-0
the pathology is positive again in this step, liver polydioxanone (PDS) as a suture material for
resection is the next choice of procedure. As the choledochoenteric anastomosis. Author uses two
right hepatic artery is generally invaded by the PDS sutures with needles on both sides. Each
tumor in hilar cholangiocarcinoma, hepatic side is anchored with 5-0 PDS. The anterior and
resection of right lobe is considered first if the posterior walls of anastomosis are sutured con-
volume of remaining lobe is greater than 35%. tinuously. If the lumen of anastomosis is less than
234 J. S. Kim

References
1. Kondo S, Takada T, Miyazaki M, et al. Guidelines for
the management of biliary tract and ampullary car-
cinoma: surgical treatment. J Hepatobiliary Pancreat
Surg. 2008;15:41–54.
2. Kim N, Lee H, Min SK, et al. Bile duct segmental
resection versus pancreatoduodenectomy for middle
and distal bile duct cancer. Ann Surg Treatment Res.
2018;94:240–6.
3. Chen RX, Li CX, Luo CH et al. Surgical strategies for
the treatment of bismuth type I and II hilar bile duct
cholangiocarcinoma: bile duct resection with or with-
out hepatectomy? Ann Surg Oncol 2020.
4. Ikeyama T, Nagina M, Odda K, et al. Surgical approach
to bismuth type I and II hilar ­cholangiocarcinomas:
Fig. 36.4 Segmental bile duct resection is completed. audit of 54 consecutive cases. Ann Surg.
The separate hepatic ducts (arrows) are converted to a 2007;246:1052–7.
single orifice after ductoplasty in this patient 5. Ebata T, Watanabe H, Ajioka Y, et al. Pathologic
appraisal of lines of resection for bile duct carcinoma.
Br J Surg. 2002;89:1260–7.
7 mm, an interrupted suture is used to avoid anas- 6. Hwang S, Lee SG, Kim KH, et al. Extended extra-
tomotic strictures after operation. Careful hemo- hepatic bile duct resection to avoid performing pan-
creatoduodenectomy in patients with mid bile duct
stasis is done. One or two drainage tubes are cancer. Dig Surg. 2008;25:74–9.
placed and the abdomen is closed layer by layer.
 Pancreatico-duodenectomy
37
Sang Geol Kim and Hyung Jun Kwon

Abstract duction in 1978 by Traverso and Longmire,

the pylorus-preserving technique is now per-
Extrahepatic bile duct cancer is defined as the
formed for most distal bile duct cancers.
presence of a malignant tumor arising at the
biliary tree distal to second-order branches.
Keywords
Extrahepatic bile duct cancer can be further
divided into hilar and distal bile duct can- Extrahepatic bile duct · Distal bile duct
cers. The site of an extrahepatic bile duct Common bile duct · Cholangiocarcinoma
cancer has clinical importance because it Surgery · Pancreaticoduodenectomy
affects the selection of the appropriate type
of surgical resection and outcomes after the
surgery. Compared to hilar bile duct cancer,
37.1 Position
which requires concomitant bile duct and
liver resection, surgical resection for a distal
The patient is placed supine on the table with 90
bile duct cancer requires pancreaticoduode-
degrees abduction of the right arm.
nectomy with regional lymph node dissection
and subsequent reconstruction with a hepati-
cojejunostomy, pancreaticojejunostomy, and
37.2 Incision and Exposure
duodenojejunostomy.
The first pancreatoduodenectomy was
While various types of incision such as oblique
described by Kausch in 1909. The procedure
or curved incision below right costal margin are
traditionally involves en bloc removal of the
employed, the authors usually prefer the midline
gastric antrum, duodenum, pancreatic head,
incision extending below umbilicus. The xiphoid
gallbladder, and bile duct. Since its first intro-
process can be excised if it is too long and xiphi-
costal angle is narrow hindering adequate expo-
Supplementary Information The online version con- sure. After opening the abdomen, the round
tains supplementary material available at https://doi. ligament is ligated and divided leaving the 2–0
org/10.1007/978-­981-­16-­1996-­0_37.
silk clamped with a hemostat at the end, which is
used to expose the liver by pulling the silk. The
S. G. Kim (*) · H. J. Kwon incision can be extended to lower the abdomen or
Department of Surgery, Kyungpook National via additional transverse incision above u­ mbilicus
University School of Medicine, Daegu, South Korea if required to ensure adequate exposure. The fal-
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 235

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_37
236 S. G. Kim and H. J. Kwon

ciform ligament is divided cranially via electro-

surgery until the triangular ligament, followed by
the application of abdominal retractors to fully
expose the upper abdomen.
To determine the resectability, the degree of
invasion of the primary tumor, gross features of
the lymph nodes, the presence of peritoneal seed-
ing, and distant metastasis need to be analyzed
systemically.
First, hepatoduodenal ligament, hepatic hilum,
tissues around celiac artery, and the pancreas
head are examined by inspection and palpation to
determine the invasiveness of the primary tumor
and the probability of lymph node metastasis.
Then, the surface of the liver is evaluated for pos-
sible metastasis. Lastly, peritoneal seeding is
examined by tracing the intestine from the Treitz
ligament to the rectovesical pouch including Fig. 37.1 Dissection between great omentum and trans-
mesentery, mesocolon, and para-aortic area. verse colon continued to hepatic flexure of ascending
colon to facilitate the mobilization of duodenum via
Kocher maneuver

37.3 Mobilization of Pancreas

Head and Duodenum

The avascular plane between the great omentum

and the transverse colon is dissected by pulling
the omentum cranially and the transverse colon
caudally. The dissection is continued to expose
the second and third portions of the duodenum,
the anterior surface of pancreas head, the right
side of superior mesenteric vein, and the infe-
rior margin of pancreas body. During this pro-
cedure, the hepatic flexure of ascending colon
can be dissected downward from the third por-
tion of duodenum to facilitate the mobilization
of duodenum by Kocher maneuver (Fig. 37.1).
Mobilization of the duodenum requires liga- Fig. 37.2 Kocher maneuver, retracting the C-loop of
tion and division of supraduodenal vessel and duodenum and pancreas head, exposes the inferior vena
right gastric artery followed by the Kocher cava, left renal vein, and right side of aorta
maneuver. The Kocher maneuver, dissecting
the duodenum off the retroperitoneum over (Fig. 37.2). During this procedure, great care is
right kidney, exposes the inferior vena cava, needed to avoid injury to the ureter and annoy-
left renal vein, and right side of aorta retract- ing bleeding from mesocolic artery and gastro-
ing the C-loop of duodenum and pancreas head colic trunk.
37 Pancreatico-duodenectomy 237

37.4 Tunneling of Pancreatic Neck 37.5 Division of Duodenum

When duodenum is completely mobilized and the The right gastroepiploic artery supplying pylorus
gastrocolic trunk is exposed, the veins from gas- and duodenum is ligated and divided at its origin
trocolic trunk draining into superior mesenteric in the gastroduodenal artery. In this area, we
vein need to be ligated and divided early to prevent included the subpyloric lymph node (no. 6) in the
tearing and bleeding. The division of these veins tissue for removal by dividing the right gastroepi-
from gastrocolic trunk mobilizes the upper part of ploic artery far distally from the origin of gastro-
superior mesenteric vein. The dissection between epiploic artery (Fig. 37.4).
SMV and inferior part of pancreatic neck proceeds As described in the procedure for Kocher
to adjacent inferior margin of pancreas body to maneuver, the supraduodenal vessel and the right
facilitate tunneling along the SMV under the neck gastric artery are divided near the gastroduodenal
of pancreas. The peripancreatic tissues of both wall to dissect suprapyloric lymphatic tissue
superior and inferior margins are dissected and the completely (no. 5) (Fig. 37.5). Although the right
transfixed bilaterally with 3–0 Prolene tagging gastric artery may be preserved to ensure blood
sutures on remnants of pancreatic body. These tag- supply, the authors usually divide the right gastric
ging sutures enable tunneling procedure and con- artery at its origin.
trol the bleeding (Fig. 37.3). The space between After dissection between pancreatic head and
SMV and pancreatic neck is usually in the avascu- duodenal c-loop to obtain adequate length of
lar plane; thus, blunt dissection by Kelly or right- duodenum, the duodenum is divided more than
angle clamp easily results in the tunnel between 2–3 cm below the pylorus using a GIA stapler.
SMV and posterior surface of pancreatic neck.

Fig. 37.3 After the division gastrocolic trunk from SMV, Fig. 37.4 Right gastroepiploic artery is ligated and
transfixing tagging sutures of 3-0 Prolene are placed on divided near the division line of duodenum
both sides of remnant pancreatic body to facilitate the tun-
neling procedure
238 S. G. Kim and H. J. Kwon

duct is followed by cholecystectomy. By pulling

the fundus of gallbladder via clamp, dissection is
used to remove the gallbladder off the bed of liver
without division of the cystic duct. Further dis-
section from right to left side of hepatoduodenal
ligament opens the serosa connected to hilar plate
and exposes the anterior surface of bile duct. The
dissection proceeds caudally along the left side
of the hepatoduodenal ligament to identify
hepatic artery, and further along the hepatic artery
proper and common hepatic artery. The origin of
right gastric artery is ligated and divided to dis-
Fig. 37.5 Supraduodenal vessels are divided near gastro- sect the lymph nodes # 5, 12a, and 8. After expos-
duodenal wall and the right gastric artery is divided at its ing hepatic artery proper and common hepatic
origin. The dissection is continued to obtain adequate artery, the right hepatic artery is traced to skele-
length of duodenum and the duodenum is divided more tonize via dissection of the lymphatic tissue leav-
than 2–3 cm below the pylorus
ing only vascular structures behind.
The gastroduodenal artery is exposed. Before
37.6 Division of Pancreatic Neck the ligation and division of the artery, the anoma-
lous origin of the hepatic artery from GDA is
Pancreatic neck is divided usually just above the confirmed utilizing a Bulldog clamp. The gastro-
SMV-portal vein but the division line may extend duodenal artery is the largest artery among the
beyond the left margin of SMV according to the arteries ligated and divided during the entire sur-
left margin of the primary tumor. gery. Because the location of the gastroduodenal
The proximal portion of the neck to be artery stump is located near the site of future pan-
removed is ligated with a 2–0 black silk before creatic jejunostomy, a significant pancreatic fis-
the division. The tagging sutures with 3–0 tula is strongly associated with pseudoaneurysm
Prolene placed on the superior and inferior bor- and lethal bleeding from gastroduodenal artery.
der of the distal portion of pancreatic neck enable The gastroduodenal artery needs to be double
the elevation of the neck during tunneling. The ligated securely.
authors prefer to divide the pancreatic neck with The dissection of the bile duct may be substan-
a knife because it provides clear resection surface tially facilitated by the skeletonization of the ves-
and easy identification of bleeding vessels. The sel. Using a right-angle dissector, the bile duct is
pulsating arterial bleeding is ligated with sutures dissected from the portal vein and isolated by a ves-
and the non-pulsating minor bleeding is con- sel loop. By pulling the vessel loop around the bile
trolled via electrosurgery. duct, the bile duct can be further mobilized to iden-
tify the right hepatic artery behind the duct. The
division line of the bile duct differs depending on
37.7 Division of Bile Duct the extension of the primary tumor and the usual
and Regional division line is on the level of hepatic bifurcation.
Lymphadenectomy The distal bile duct is ligated. The lymph
nodes around portal vein (12b, 12p) are dissected
The regional lymphadenectomy around hepato- after the bile duct is divided and dissected off the
duodenal ligament starts with longitudinal dis- portal vein. Proximal resection margin should be
section of the hepatoduodenal ligament and examined by frozen biopsy to determine the need
opening of the lesser sac. The isolation of bile to resect the bile duct further.
37 Pancreatico-duodenectomy 239

37.8 Division of Jejunum 37.9 Dissection of Uncinate

Process, Retroperitoneal
Jejunum is divided about 15-cm distal from Tissues, and Nerve Plexus
Treitz ligament. The vascular pattern of the
jejunal mesentery is identified by transillumi- 37.9.1 Dissection of Uncinate
nating the mesentery to determine the line of Process
mesenteric division. In order to dissect the
first jejunal branch of SMA, the division of Uncinate process of pancreas is located behind
mesentery occurs near the mesenteric border SMV usually extending to immediate right of
of proximal jejunum. Because the proximal superior mesenteric artery, rarely extending to
jejunum is actively involved in the absorption the left beyond SMA. The nerve plexus is divided
of nutrients, it is better to leave behind as and the arteries between SMA and uncinate pro-
much as possible avoiding excessive tension cess are ligated and divided by retracting the por-
and ischemia of the intestine. The first jejunal tal vein to the left using a vein retractor and
branch of SMA is ligated and divided after pulling the uncinated process to the right side.
rotating the divided proximal jejunum under
superior mesenteric vessels, followed by the
dissection of SMA nerve plexus and lymph 37.9.2 Retroperitoneal Tissues
nodes (Fig. 37.6).
Pulling the pancreatic head to the right side and
retracting portomesenteric trunk to the left side
with a vein retractor, the retro-pancreatic connec-
tive tissues adjacent to pancreatic head contain-
ing vessels are ligated and divided. Great caution
should be taken to avoid troublesome bleeding
from the arterial branches from SMA (Fig. 37.7).

37.9.3 Dissection of Lymph Nodes

and Nerve Plexus around
SMA

Primary tumor and metastatic lymph nodes

around SMA often invade the nerve plexus; thus,
we prefer dissection of lymph nodes in a lump
Fig. 37.6 After the division of pancreatic neck just above with nerve plexus around SMA. When the pan-
the SMV, the divided proximal jejunum is rotated under creatic head is pulled to the right after dividing
superior mesenteric vessels, followed by ligation of the
the pancreatic neck, the nerve plexuses can be
first jejunal branch of SMA and division of the right side
of SMA
240 S. G. Kim and H. J. Kwon

Fig. 37.7 Retracting portomesenteric trunk to the left Fig. 37.8 Retracting portomesenteric trunk to the left
side, uncinated process, nerve plexus, and vessels such as side using a vein retractor, the nerve plexus to the right of
inferior pancreaticoduodenal artery are ligated and SMA and celiac trunk is dissected in a lump containing
divided the lymph nodes and retroperitoneal tissues and resected
combined with pancreas head

identified from the uncinated process along

SMA, common hepatic artery, and celiac trunk. right side of celiac axis is dissected and resected
Pulling the divided jejunum to the right side of combined with pancreatic head (Fig. 37.8).
SMA after dividing the first jejunal branch of
SMA, the nerve plexus near uncinated process is
dissected longitudinally upward. The dissection 37.10 Reconstruction
of nerve plexus is continued upward retracting
the SMV to the left with a vein retractor. Finally, 37.10.1 Pancreaticojejunostomy
the nerve plexus is dissected off the SMA in a
lump containing the lymph nodes and retroperi- The blind end of the divided jejunum is pulled
toneal tissues. through the opening of mesocolon along the
Several vessels including inferior pancreatico- retro-colic route and placed near the proximal
duodenal artery branching from SMA should be end of remnant pancreas. Since we utilize the
carefully ligated. The occasional right hepatic inverted mattress pancreaticojejunostomy, a kind
artery from SMA should be carefully handled to of invagination technique, the superior and infe-
avoid injury. The remaining tissue during the dis- rior margins of the remnant pancreas are mobi-
section of lymph nodes and nerve plexus is lized for easy insertion inside the jejunum. Every
ligated to prevent lymphorrhea. Following the active bleeding point of pancreatic cut surface is
dissection of nerve plexus around SMA, the pan- securely controlled with a 4–0 Prolene to prevent
creatic head is connected to the root of celiac axis postoperative intraluminal bleeding. The size of
by the retro-pancreatic tissues carrying the SMA external stent is determined after identification of
nerve plexus. Finally, the nerve plexus on the pancreatic duct.
37 Pancreatico-duodenectomy 241

The inverted mattress pancreaticojejunostomy

is an invagination technique, in which the proxi-
mal remnant pancreas is inserted through the
opening created in antimesenteric side wall of
jejunum. The jejunum and inserted proximal
jejunum are secured by four U-shaped mattresses
and one suture at each corner; thus, a total of 5–6
sutures are placed between jejunum and the rem-
nant pancreatic body. This suture technique is
easy and reduces tangential shear force with a
reduced risk of significant pancreatic fistula.
Since the cut surface of pancreas is exposed Fig. 37.9 Three to four U-shaped mattress sutures (4-0
Prolene) are made starting at the mucosa of posterior jeju-
inside the jejunal lumen without contacting tis- nal wall using a double-arm non-absorbable 4-0 monofila-
sues, the pulsating bleeding from cut surface of ment. The tagging sutures of 3–0 Prolene placed at both
pancreas is securely sutured with a non-­ superior and inferior border of pancreas body used for
traction after penetrating the jejunum from inside to out-
absorbable monofilament.
side of the jejunal wall
The inverted mattress technique for pancre-
atojejunostomy is described below. U-shaped sutures going out-in followed by a
full-thickness stitch of anterior jejunal wall
1. Antimesenteric border of the proximal jeju- going in-out, thereby invaginating the proxi-
num is longitudinally opened with the same-­ mal pancreatic body into the lumen of
sized pancreatic cut surface via jejunum.
electrosurgery. 6. Finally, the U-sutures were placed in both cor-
2. External stent is inserted through a small ners of jejunum. The needle is placed on one
opening of jejunum into pancreatic duct. side of jejunal corner inverting the seromus-
3. Based on the location of the pancreatic duct cular layer followed by penetration of a corner
and the size of the cut surface, the number of of pancreatic body. The needle is passed
sutures is determined. If the duct is located at through the other side of jejunal corner out-in
the center of pancreatic cut surface, four followed by a full-thickness stitch, invaginat-
U-shaped mattress sutures are placed, and if it ing the corner of proximal pancreatic body
is located on the periphery of cut surface, into the lumen of jejunum.
three U-shaped mattress sutures are placed. 7. All five to six stitches are tied carefully at the
The U-shaped mattress sutures (4–0 Prolene) anterior wall and both corners of the jejunum
are made starting at the mucosa of posterior enclosing the jejunal opening around the pan-
jejunal wall using one arm of non-absorbable creas remnant (Fig. 37.10).
4–0 monofilament, going in-out through the
full thickness of jejunum (Fig. 37.9). The
other arm is also used similarly going in-out 37.10.2 Hepaticojejunostomy
through the full thickness of jejunum.
4. Both arms of 4–0 monofilament penetrate the Since the bile duct is usually dilatated in cases of
proximal end of remnant pancreatic body extrahepatic bile duct cancer, the authors prefer
straight constituting a unit of U-shaped mat- continuous hepaticojejunostomy. According to
tress suture. Totally, 3–4 U-shaped mattress the size of the bile duct, a smaller jejunal opening
sutures are completed between the posterior than the bile duct is created via electrosurgery.
wall of jejunum and the proximal pancreatic The 4–0 absorbable monofilament (PDS) sutures
body. are placed between the bile duct and the jejunal
5. The sero-muscular layer of anterior jejunal wall at both right and left corners. Continuous
wall is inverted by the transpancreatic intraluminal running sutures of posterior walls
242 S. G. Kim and H. J. Kwon

Fig. 37.11 In case of dilated bile duct, continuous hepat-

Fig. 37.10 Anterior wall of jejunum is sutured with the icojejunostomy is performed
transpancreatic U-shaped sutures. The sero-muscular
layer of anterior jejunal wall was inverted going out-in,
followed by a full-thickness stitch of anterior jejunal wall antimesenteric border of jejunum. Two double-arm
going in-out. The traction of 3-0 prolene tagging sutures
PDS are placed through the full thickness of duo-
facilitates invagination of proximal pancreatic body into
the lumen of jejunum and all four U-shaped sutures are denal and jejunal walls at both right and left corners
tied at the anterior wall jejunum with all the needles inside the lumen. After tying at
the right corner intraluminally, one single arm is
passed through duodenal wall in-out and left out-
are performed from the left to the right corner. side the duodenal wall to be utilized in anterior
Once the posterior wall sutures are completed, continuous running. The other single arm is uti-
the anterior wall sutures are performed from the lized to perform intraluminal continuous running
left to the other side. Hepaticojejunostomy is from right corner to left corner suturing posterior
completed after tying both posterior and anterior walls. Once the running suture of posterior wall
running sutures after completing the anterior wall reaches the other end, all three arms are tied. At the
(Fig. 37.11). left corner, a single arm is passed through duodenal
wall in-out and through jejunal wall out-in in
extramucosal anastomosis. The stitches run a quar-
37.10.3 Duodenojejunostomy ter of anterior wall leftward in the same manner.
The remaining single arm on the right side is uti-
The authors anastomose duodenum and jejunum at lized in continuous extramucosal running sutures
least about 40 cm apart from the opening of meso- for anterior walls. After running 3 quarters of ante-
colon anterior to the T-colon via continuous sutures rior wall, the suture is completed tying with the
using 4–0 absorbable monofilament (4–0 PDS). other single arm from left corner. If it is required,
According to the size of opening in the divided several reinforcement stitches are made to secure
duodenum, an appropriate opening is created at the the anastomosis. (Fig. 37.12).
37 Pancreatico-duodenectomy 243

37.11 Insertion of Drain

and Closure

Openings at mesocolon and Treitz ligament are

closed to prevent internal hernia. Drainages are
placed near hepaticojejunostomy and pancreati-
cojejunostomy. The abdomen is closed layer by
layer after confirming the absence of bleeding
and other complications.

Fig. 37.12 Continuous duodenojejunostomy: Two

double-­arm PDS are placed at both right and left corners
with the all needles inside of the lumen. After tying at the
right corner intraluminally, a single arm was run to suture
the posterior wall and tied with the other double arm at the
left corner, where a single arm passes through the duode-
nal wall in-out and through jejunal wall out-in as in
extramucosal anastomosis in addition to a quarter of ante-
rior wall leftward in the same manner. The remaining
single arm in the right suture anterior wall was run left-
ward in the method of extramucosal anastomosis. Finally,
the suture is completed by tying with the other single arm
from the left corner
 Hepatopancreatoduodenectomy
38
Shin Hwang

Abstract 38.1 Indications

and Contraindications
Hepatopancreatoduodenectomy (HPD) is a
combination of hepatectomy and pancreatico-
The primary indications for HPD are diffuse bile
duodenectomy. Its primary indications are dif-
duct cancer and advanced gallbladder cancer
fuse bile duct cancer and advanced gallbladder
involving the peripancreatic lymph nodes [1–4].
cancer involving the peripancreatic lymph
Localized extrahepatic bile duct cancer,
nodes. Since each phase of surgery is associ-
which is not diagnosed with diffuse bile duct
ated with high operative risk, it is important to
cancer, is an indication for hepatic resection if
lower the risk by reasonably adjusting the
the hepatic bile duct resection margin is tumor-
extent of hepatectomy, obviating the need for
positive on intraoperative frozen-section biopsy
excessive and unnecessary dissection of the
during bile duct resection. Another indication for
neural plexus around the hepatic arteries, and
pancreaticoduodenectomy is tumor-positive dis-
insertion of multiple abdominal drains.
tal bile duct resection margin following intraop-
erative frozen-section biopsy during extended
Keywords
bile duct resection excavating the intrapancreatic
Diffuse bile duct cancer · Gallbladder cancer bile duct. Consequently, if both proximal and
Hepatectomy · Pancreaticoduodenectomy distal bile duct resection margins are tumor-pos-
Post-hepatectomy hepatic failure itive, HPD is indicated [1, 2]. In contrast, since
Postoperative pancreatic leak · Complication HPD is considered a high-risk surgery for non-
Lymph node metastasis · abdominal drain curative resection leading to microscopic tumor-
positive resection margins, it is selectively
performed to achieve curative resection with a
high probability [4].
In case of advanced gallbladder cancer, pan-
creaticoduodenectomy is indicated if hepatec-
tomy and bile duct resection cannot ensure
complete removal of the tumor including the
S. Hwang (*)
Division of Hepatobiliary Surgery and Liver regional lymph nodes due to extensive involve-
Transplantation, Department of Surgery, Asan ment of the peripancreatic lymph nodes [3].
Medical Center, University of Ulsan College of However, the outcome of HPD in advanced gall-
Medicine, Seoul, South Korea bladder cancers with deep involvement of the
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 245

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_38
246 S. Hwang

hepatic parenchyma or suspected involvement of to 3 cm. If excessive tension is applied to the site
the para-aortic lymph nodes is associated with a of portal vein anastomosis due to forceful pulling
high risk of early tumor recurrence leading to after portal vein resection, the risk of anastomotic
futile surgery [5, 6]. stenosis increases. Therefore, for resection of a
long segment of the portal vein, interposition can
be performed using a homologous or autologous
38.2 Preoperative Evaluation vascular conduit.
and Design for Surgical The risk of postoperative pancreatic leak in
Resection pancreaticoduodenectomy is largely determined
by the condition of the pancreatic parenchyma. In
HPD can be divided into pre-planned and intra- case of chronic pancreatitis or dilated pancreatic
operative categories for more aggressive surgery. duct, aggressive periarterial plexus dissection is
In the case of pre-planned operation, if the hepatic allowed because the risk of pancreatic leak is
parenchymal resection rate is more than 60% for relatively low. However, in the case of normal
right hepatectomy, preoperative right portal vein pancreas, it is better to avoid complete peeling of
embolization is recommended to prevent liver the neural plexus around the hepatic artery over
failure after surgery. In surgically confirmed the entire length.
cases, it is safe to perform hepatectomy only
when the rate of hepatic parenchymal resection is
less than 60%. Not only does massive hepatic 38.3 Surgical Techniques
resection cause hepatic insufficiency, but the
decrease in hepatic function due to massive Except for cases in which the gallbladder cancer
hepatic resection significantly delays recovery is widely infiltrated and there is a risk of tumor
and incidence of infection at the site of pancreati- cells spreading during transection of the tumor in
coduodenectomy [7]. the mid-portion of the common bile duct, HPD
If the reason for hepatic resection in biliary does not require resection of the liver–biliary
tract cancer is to secure tumor-free hepatic duct tract–pancreas–duodenum in a single mass. In the
resection margins, the hepatic parenchymal resec- case of diffuse biliary cancer, since the extrahe-
tion rate can be decreased via left hepatectomy or patic biliary tract is transected to confirm the bile
central parenchyma-preserving hepatectomy. If duct resection margins, surgical resection is per-
the reason for hepatic resection is removal of the formed on the hepatic and the pancreatic sides.
hepatic infiltrating tumor in the gallbladder cancer, Hepatic resection depends on the patterns of
the prognosis is not significantly affected even if hepatic duct invasion. Since the left hepatic duct
only a 2-cm-deep hepatic resection margin is is relatively long, it is easy to obtain a tumor-­
secured via extended cholecystectomy or central negative resection margin, so HPD including
partial hepatectomy. In gallbladder cancer, unlike right hepatectomy is generally performed
perihilar bile duct cancer, the caudate bile duct is (Fig. 38.1). However, it is advisable to avoid right
rarely infiltrated; thus, it is usually unnecessary to hepatectomy with a hepatic parenchymal resec-
remove the caudal lobe concurrently. tion rate of 60% or more unless previously
When the pancreatic duct is not enlarged and planned before surgery. The caudate lobe should
the pancreatic parenchyma is normal, the risk of be excised altogether given the tumor progres-
postoperative pancreatic leak after HPD is ele- sion in diffuse bile duct cancer. Therefore, left
vated. Thus, special attention is needed during hepatectomy combined with caudate lobectomy
hepatic artery resection due to hepatic artery is one of the preferred methods.
invasion because of the high risk of rupture or As for hepatic parenchyma-preserving resec-
pseudoaneurysm at the arterial anastomosis [8]. tion, the conventional approach is resection of the
Portal vein invasion can be treated with end-­ left medial section (segment IV) via caudate
to-­end anastomosis after segmental resection up lobectomy (Fig. 38.2). Although this extent of
38 Hepatopancreatoduodenectomy 247

surgery is technically difficult and requires recon- In diffuse biliary cancer, conventional pancre-
struction of both left and right hepatic ducts aticoduodenectomy is performed since the depth
(Fig. 38.3), the hepatic parenchymal resection of bile duct wall infiltration within the pancreas is
rate is as low as 15%. Because it is low enough, it not severe. In the case of normal pancreas, a pan-
has the advantage of virtually no risk of liver fail-
ure and can be performed in almost all cases
without invading the major blood vessels in the
hepatic hilum.

Fig. 38.3 Extent of resection in hepatopancreatoduode-

nectomy performed in a patient with diffuse bile duct can-
cer. The ventral portions of the segment IV, segment V, and
caudate lobe were resected, and pylorus-preserving pan-
creaticoduodenectomy was performed. The photograph
Fig. 38.1 Resection in a patient with diffuse bile duct shows the preparation for biliary reconstruction after pan-
cancer treated with right hepatopancreatoduodenectomy. creato-enteric anastomosis. As shown in the illustration, a
The right lobe and caudal lobe were excised, and the wide gap is made between the anastomoses at the jejunal
remaining left lobe with three bile ducts exposed. Right limb side to anastomose the left and right bile ducts easily.
portal vein embolization was performed before surgery; Braun jejunojejunostomy was performed in the middle
thus, the left liver is significantly enlarged. The left renal portion in order to prevent the pancreatic fluid flowing into
vein was encircled with a vascular loop for para-aortic the jejunum through the pancreatic-jejunal anastomosis
lymph node resection from entering the biliary-enteric anastomosis

Fig. 38.2 Extent of hepatic parenchyma-preserving resection performed in a patient with diffuse bile duct cancer. The
entire segment IV and caudate lobe were excised
248 S. Hwang

creatic anastomosis at the pancreatic body after 38.4 Risks and Pitfalls During
resecting the pancreas more than 2–3 cm to the Surgery
left of the portal vein completely exposes the
superior mesenteric and splenic vein confluence Liver failure and pancreatic leak are the major
and reduces the risk of pancreatic leakage surgical complications associated with HPD,
(extended pancreaticoduodenectomy). resulting in severe outcomes. Therefore, special
In patients with advanced gallbladder cancer, care should be taken to prevent such major
if metastatic lymph nodes do not directly infil- complications.
trate the pancreatic parenchyma, only lymph Hepatic insufficiency is primarily due to
node dissection is usually performed. Because excessive hepatic resection and rarely occurs
the surgical field of view is relatively well secured unless right hepatectomy is performed. If right
via bile duct resection alone, it is possible to hepatectomy with a parenchymal resection rate
extensively dissect lymph nodes around the pan- of more than 60% is required, portal vein embo-
creatic head. When the metastatic lymph nodes lization before surgery is recommended to reduce
locally infiltrate the pancreatic parenchyma, a the parenchymal resection rate [7].
small amount of pancreatic parenchyma can be The incidence of pancreatic leak following
removed at the lymph node level. Considering pancreaticoduodenectomy is quite high in normal
the poor prognosis after surgery due to extensive pancreas. If there is such a risk, it is better to
peripancreatic lymph node metastasis, it is rare to avoid excessive periarterial neural plexus dissec-
perform combined pancreatoduodenectomy only tion so that the arteries can partially withstand
for extensive lymph node dissection. exposure to pancreatic fluid.
Pancreatoduodenectomy is contraindicated if Fibrin glue can be applied to the hepatic artery
direct infiltration of the duodenum and gastric dissection sites to form a protective film. The
pyloric area is not clearly visible on the preopera- greater omentum can be separated to form an
tive imaging studies, because it is usually locally omental flap, which can be placed between the
resectable. Extensive invasion of the common common hepatic artery and the pancreatic anas-
bile duct along the cystic duct may be an indica- tomosis to prevent pancreatic anastomotic leak-
tion for pancreaticoduodenectomy. age [9]. However, these protective measures are
In cases where the gallbladder carcinoma is not effective once an anastomotic leakage occurs,
not associated with severe lymph node metastasis so efficient intraperitoneal drainage tubes must
but involves extensive invasion of the surround- be inserted in advance. The Jackson-Pratt type
ing tissues, pancreaticoduodenectomy may be drainage tube has a relatively poor drainage effect
performed for complete tumor resection. A large on abscess fluid induced by pancreatic leak due
gallbladder mass is not uncommon in cases to its structural limitation. Therefore, it is effec-
where the gallbladder cancer is associated with tive to insert a number of reliable Penrose or
xanthogranulomatous cholecystitis. In advanced Cigarette drainage tubes [8, 10].
gallbladder cancer, hepatic parenchyma-­ If the drainage tube is inserted from the right
preserving resection, such as central hepatec- side around the pancreatic anastomosis, it is dif-
tomy, is more commonly performed than major ficult to discharge the stuff that accumulates in
hepatic resection. Resection of the right lobe the resection site of the pancreatic head and unci-
requires accurate evaluation of the extent of nate process. Thus, it is necessary to insert at
hepatic parenchymal resection because it entails least one drainage tube from the left upper abdo-
extended right hepatectomy due to the location of men toward the hepatic hilum along the path
the gallbladder. from which the duodenum was removed [10, 11].
38 Hepatopancreatoduodenectomy 249

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tions for operation can be expanded. Conversely, Biliary-­Pancreat Surg. 2007;14:142–8.
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as well as variable hepatectomy including right PC. Liver regeneration following extended liver resec-
hepatectomy. The indications for this aggressive tion combined with pancreatoduodenectomy. Korean
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of resection is usually fixed in pancreaticoduode- coduodenectomy. Ann Hepatobiliary Pancreat Surg.
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Makuuchi M. Two-staged pancreatoduodenectomy
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patients who can expect to improve their progno- tal graft technique. J Am Coll Surg. 1998;187:103–5.
sis following extended aggressive resection. 10. Hwang S, Jung DH, Ha TY. Application of suction-­
Precise evaluation before surgery and delicate type cigarette drain in leak-prone hepatopancreato-
biliary surgery. Ann Hepatobiliary Pancreat Surg.
surgical intervention to prevent complications are 2020;24:305–8.
required in order to decrease the risk of surgery. 11. Yoon YI, Hwang S, Cho YJ, Ha TY, Song GW, Jung
DH. Therapeutic effect of trans-drain administration
of antibiotics in patients showing intractable pancre-
atic leak-associated pus drainage after pancreaticodu-
References odenectomy. Korean J Hepatobiliary Pancreat Surg.
2015;19:17–24.
1. Ebata T, Yokoyama Y, Igami T, Sugawara G, Mizuno
T, Nagino M. Review of hepatopancreatoduodenec-
tomy for biliary cancer: an extended radical approach
 Part VIII
Operative Technique of Pancreatectomy
 Pylorus-Preserving
Pancreaticoduodenectomy 39
Dong Sup Yoon and Joon Seong Park

Abstract centers because of advances in intraoperative and

postoperative care, as well as technical refine-
Pancreaticoduodenectomy (PD) is the stan-
ments [2].
dard surgical treatment for tumors of the pan-
creatic head, proximal bile duct, duodenum,
and ampulla. Since its initial description by
39.1 Surgical Techniques
Whipple et al. in the 1930s, it has evolved and
undergone several modifications. The devel-
39.1.1 Patient Position and Skin
opment of specialist units has contributed to a
Incision
marked reduction in postoperative mortality
from approximately 30% to 5–6% or less.
Adequate exposure is mandatory for safe
PPPD. The patient is positioned supine and a
Keywords
midline incision is performed (Fig. 39.1). An
Pancreatic resection · abdominal retractor is used for secure retraction.
Pancreatoduodenectomy A thorough abdominal exploration is used to
investigate peritoneal or hepatic metastases,
focused on the pelvis for unexpected metastases.
Since its introduction in 1978 by Traverso and
Long-mire, pylorus-preserving pancreaticoduo-
denectomy (PPPD) has become the standard of 39.1.2 Kocher Maneuver
treatment in periampullary disease [1]. Current
mortality rates are 3% or less at high-volume Occasionally, the hepatic flexure of the colon is
released inferiorly, and a Kocher maneuver is
performed to elevate the duodenum and the head
Supplementary Information The online version con- of pancreas. Kocher maneuver should be per-
tains supplementary material available at https://doi. formed to the left of the abdominal aorta. The
org/10.1007/978-­981-­16-­1996-­0_39. dissection is conducted cephalad above the retro-
choledochal lymph node, inferior to the trans-
D. S. Yoon (*) · J. S. Park verse duodenum, and medially to the aorta
Pancreatobiliary Cancer Clinic, Department of (Fig. 39.2).
Surgery, Gangnam Severance Hospital, Seoul,
South Korea
e-mail: [email protected]; [email protected]

© Springer Nature Singapore Pte Ltd. 2023 253

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_39
254 D. S. Yoon and J. S. Park

carried out from the right to the left, to complete

separate the omentum from the right transverse
mesocolon. The lesser sac is entered, and the
entire anterior aspect of the pancreas is explored
(Fig. 39.3a, b).

39.1.4 Duodenal Surgery

The right half of the omentum is mobilized and

the proximal pancreas exposed, followed by the
identification of middle colic vein down to its
junction with the SMV. Exposing the lateral
aspect of the SMV, the right lateral SMV is fol-
lowed in a cephalad direction to the gastrocolic
venous trunk. The gastrocolic trunk is ligated
with fine sutures and divided (Fig. 39.4a, b). The
right gastroepiploic artery and vein are divided
and the stomach is retraced directly anteriorly,
followed by duodenal traction. (Fig. 39.5) The
duodenum can be severed at this time with GIA
2–3 cm distal to the pylorus (Fig. 39.6a, b).

Fig. 39.1 Midline incision 39.1.5 Dissection of Lesser Sac

The gastrohepatic omentum beneath the left

lobe of liver incised in an avascular manner
carefully protects the nerves of Latarjet. Tissues
anterior to the hepatoduodenal ligament are
carefully incised and the right gastric artery
divided. The common hepatic artery is identi-
fied and retraced (Fig. 39.7). The plane between
the superior border of the pancreas and the
common hepatic artery is dissected superiorly,
and PV is identified. GB is mobilized from
GB bed above downward. The cystic artery is
ligated and divided. The common bile duct is
Fig. 39.2 Kocher Maneuver
palpated posteriorly to determine the presence
of the accessory or the right hepatic artery aris-
39.1.3 Pancreatic Approach ing from the SMA is replaced. The bile duct is
then mobilized along the plane between the PV
The omentum is freed from the transverse colon and the common hepatic duct, and clamped and
in an avascular manner. The omental dissection is severed (Fig. 39.8).
39 Pylorus-Preserving Pancreaticoduodenectomy 255

Fig. 39.3 Omentectomy

39.1.6 Division of the Pancreas Hemostasis is completed. The superior and

inferior longitudinal pancreatic arteries are
The space under the pancreatic neck anterior to secured by suture ligatures. The end of the pan-
superior mesenteric vein is suitable for dissection. creas must be freed up for about 2 cm before the
Using a blunt clamp alternately advancing and anastomosis is attempted, and any bleeding must
spreading, a plane is then developed between the be controlled via electrocoagulation or inter-
pancreatic neck anteriorly and the SMV-PV con- rupted sutures (Fig. 39.9a, b).
fluence posteriorly. A blunt clamp is then placed Intraoperative assessment of the flow through
behind the pancreatic neck and slightly elevated. the hepatic artery is performed before GDA
The pancreatic neck is divided carefully. The con- ligation.
sistency of the pancreas and the size of the pan- If median arcuate ligament syndrome is diag-
creatic duct is noted, and a specimen from the nosed during procedure, the median arcuate liga-
neck of the pancreas is removed and submitted as ment must be divided before GDA ligation. GDA
margin. Bleeding from the transected pancreas is is identified and double-ligated after confirming
controlled with sutures and ligated as needed. the flow in the hepatic artery (Fig. 39.10a, b).
256 D. S. Yoon and J. S. Park

Fig. 39.4 Gatrocolic Trunk Approach

39.1.7 Mobilization of the Ligament access to the anterior aspect of the SMA. The
of Treitz and SMA Dissection adventitia of the SMA is incised carefully, expos-
ing the SMA, followed by dissection posteriorly
The ligament of Treiz is mobilized, and the tis- along the right side of the pancreas. It should be
sues to the right of the IMV are incised. The noted that the arterial branches originating from
bowel is then transilluminated approximately the posterolateral aspect of the SMA are very fri-
20 cm beyond the ligament of Treitz, and a mes- able, easily avulsed, and may trigger annoying
enteric window is fashioned. The bowel is stapled hemorrhage (Fig. 39.11a, b).
and transected. With anterior and lateral traction
on duodenum, the dissection is carried to a point
at which the uncinate process is visible. Vein 39.1.8 Reconstruction
retractors are then applied to the SMV-PV con- and Pancreaticojejunostomy
fluence, and the PV is retracted to the patient’s
left, which allows retraction of the SMV-PV con- An opening is made in the mesocolon to the
fluence to the left and anteriorly and provides right of the middle colic vessels, through which
39 Pylorus-Preserving Pancreaticoduodenectomy 257

the jejunum passes. Preparations are made for

the end-to-side pancreaticojejunostomy. The
anastomosis is facilitated by mobilizing the
­
pancreatic stump to elevate the stump anteri-
orly. With interrupted 4-0 vicryl sutures, the
pancreatic parenchyma is sutured transversely
to the seromuscular layer of the jejunum. A
small opening is made with an insulated point
cautery in a full-thickness stitch in the jejunum
adjacent to the pancreatic duct. A silastic cath-
eter with a diameter somewhat smaller than the
pancreatic duct is inserted into the jejunal open-
ing. The duct-to-mucosa anastomosis is created
with interrupted 5-0 non-­ absorbable sutures
with the posterior row completed tied. The
silastic catheter is then advanced into the pan-
creatic duct to facilitate the anterior row of
sutures and to prevent inadvertent suturing of
anterior and posterior walls of the anastomosis.
The sutures are placed inside-out on the jeju-
num and outside-in on the pancreatic duct, and
tied. The anterior row of the anastomosis is
completed with interrupted 4-0 vicryl sutures
(Fig. 39.12a, b, c, d).
Fig. 39.5 Rt. gastroepiploic artery/Vein ligation

Fig. 39.6 Duodenal divided with GIA

258 D. S. Yoon and J. S. Park

39.1.9 Hepaticojejunostomy
and Duodenostomy

Approximately 8–10 cm distal to the pancreati-

cojejunostomy, an end-to-side biliary enteric
anastomosis is performed. A single layer of non-­
absorbable interrupted suture is used through all
layers (Fig. 39.13). Approximately 25–30 cm
distally, an end-to-side duodenojejunal anasto-
mosis is created in two layers: an inner layer with
a running suture of vicryl and an outer layer with
permanent interrupted sutures (Fig. 39.14). Two
JP drains are placed posterior to the biliary and
pancreatic anastomoses.

Fig. 39.7 Dissection of Lesser SAC

Fig. 39.8 Identify of CBD

39 Pylorus-Preserving Pancreaticoduodenectomy 259

Fig. 39.9 Division of Pancreas

Fig. 39.10 GDA ligation

Fig. 39.11 SMV and SMA dissection

260 D. S. Yoon and J. S. Park

Fig. 39.12 Pancreatojejunostomy

39 Pylorus-Preserving Pancreaticoduodenectomy 261

References
1. Traverso LW, Longmire WP Jr. Preservation of the
protrusion pancreatoduodenectomy. Surg Gynecol
Obstet. 1978;146:959–62.
2. Yeo CJ, Cameron JL, Sohn TA, et al. Six hundred fifty
consecutive pancreatoduodenectomies in the 1990s:
pathology, complications, and outcomes. Ann Surg.
1997;226:248–60.

Fig. 39.13 Hepaticojejunostomy

Fig. 39.14 Duodenojejunostomy

 Radical Antegrade Modular
Pancreatosplenectomy (RAMPS) 40
Sung Su Yun and Dong-Shik Lee

Abstract node. This procedure ensures the full visual-

ization of the retroperitoneal plane of dissec-
Conventional distal pancreatectomy for pan-
tion and enables high negative resection
creatic cancer in the body or tail proceeds in a
margin and a large number of lymph node
left-to-right retrograde fashion, which results
retrieval.
in mobilization of the spleen and pancreas
before dissection for the lymph node removal
Keywords
and vessel ligation. This approach has been
associated with high positive margin rates and RAMPS · Pancreas body · Tail cancer
low lymph node (celiac and superior mesen-
tery artery node) retrieval rate due to limita-
tion of visualization for posterior plane of
40.1 The Procedure
pancreas dissection. To overcome these prob-
lems, Strasberg et al., in 2003, introduced a
40.1.1 Skin Incision
novel method of operation for pancreatic can-
cer in the body and tail—radical antegrade
‘L’-shaped incision or midline incision usually is
modular pancreatosplenectomy (RAMPS).
performed.
(Steven et al. Surgery. 133:521–7, 2003;
Strasberg and Fields, Cancer J. 18:562-70,
2012; Hyo Jun Park et al. World J Surgery, 38:
40.1.2 Expose of Pancreas
86–193, 2014) RAMPS proceeds in a right-to-­
left antegrade fashion, with early parenchymal
The omentum between the colon and the stomach
transection of pancreas, ligation of splenic
is separated with vessel sealing device which
vessels, dissection of celiac, and SMA lymph
provides advantages such as shorter operating
times and less bleeding during the entire opera-
Supplementary Information The online version con- tion process. When the omental dissection is
tains supplementary material available at https://doi. completed, the gastrosplenic ligament is com-
org/10.1007/978-­981-­16-­1996-­0_40.
pletely excised so that the stomach can be driven
to the right from spleen. The short gastric vessels
S. S. Yun (*) · D.-S. Lee contained in gastrosplenic ligament are common
Department of Surgery, Yeungnam University, causes of postoperative bleeding, so they must be
College of Medicine, Daegu, South Korea safely ligated using hemolock clip or metal clip
e-mail: [email protected]; [email protected]

© Springer Nature Singapore Pte Ltd. 2023 263

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_40
264 S. S. Yun and D.-S. Lee

along the stomach side. The colon is separated 40.1.5 Ligation of Splenic Vessels
from the spleen by dividing the splenocolic liga- and Dissection of Lymph Node
ment. When we can see the whole pancreas, the
location and boundary of the tumor are confirmed In the extension line of lymph node dissection
through palpation and ultrasound. around the common hepatic artery, celiac node
dissection can be done around the origins of the
left gastric, hepatic, and splenic arteries, but
40.1.3 Kocherization ligation of the left gastric artery should be
judged depending on the progression of disease.
A Kocher maneuver is performed until we can In this way, the origin of the splenic artery is
expose the anterior surface of the left renal vein identified and divided. And then, the splenic
and the left of the aorta. Strasberg et al. recom- vein is isolated at its junction with the superior
mended to put the gauze in the plane between left mesenteric vein and divided. The further dissec-
renal vein and pancreas. This procedure will pro- tion is carried, dividing fat, and fibrous tissue
vide easier to find dissection plane of dorsal bor- until we can see the left side of the superior
der of RAMP in later. mesenteric artery. The left sides of the superior
mesenteric and celiac arteries should now be
visible down to the point that they come off the
40.1.4 Dividing Neck of the Pancreas aorta. The lymph nodes anterior to the aorta
between the celiac artery and superior mesen-
Retroperitoneal dissection of the lower border of teric artery and those anterior and to the left of
the pancreas is performed near the neck of the the superior mesenteric artery are taken with
pancreas to find the superior mesenteric vein. this step.
And then dissect as much as possible between the
posterior surface of the pancreas and the superior
mesenteric vein to expose the splenic vein and 40.1.6 Determination of Posterior
portal vein. After the lesser omentum is opened to Plane of Dissection
find the proper and common hepatic artery, the
right gastric artery is divided to facilitate lymph When a rim of normal pancreas remains posterior
node dissection and expose of surrounding vas- to the tumor, the anterior RAMPS is chosen
cular structures. After dissection toward the com- (Fig. 40.1). When the posterior margin of the
mon hepatic artery and proper hepatic artery, the tumor contacts or seems to break through the
lymph node around the common hepatic artery posterior capsule of the pancreas, the posterior
and the left margin of the portal vein are removed RAMPS is selected (Fig. 40.2).
and then mobilize the common hepatic artery
from the upper border of the pancreas. After this 1. Anterior RAMPS
process, we can get a non-vascular tunnel The left renal vein is the point for the
between the pancreas and SMV. How to divide inferior line of the RAMPS technique. The
neck of the pancreas depends on the surgeon’s left renal vein should be found during dissec-
preference. In these days, most surgeons like to tion of the lymph nodes and fibrous tissues
use a stapler which depends on the hardness and around the left margin of the superior mesen-
thickness of the pancreas. teric artery and aorta. The adrenal veins are
40 Radical Antegrade Modular Pancreatosplenectomy (RAMPS) 265

Fig. 40.3 Real picture taken after posterior RAMPS.

A aorta; B left gastric artery; C splenic artery; D renal
vein; E kidney

Fig. 40.1 Red line shows planned plane of posterior dis-

section as shown in preoperative CT scan in anterior 2. Posterior RAMPS
RAMPS in which the tumor has not penetrated the poste- In the posterior RAMPS, the adrenal vein
rior capsule of the pancreas. A left adrenal gland; K kid-
is divided at its termination into the left renal
ney; T tumor
vein, and the dissection is carried to the left
and posteriorly behind the adrenal gland and
onto the surface of the kidney. The view at the
end of the dissection is shown in Fig. 40.3 [1]

40.1.7 Combined Resection of Other

Organs

If there is local invasion to the surrounding

organs, such as the stomach, large intestine, and
mesentery of the colon, combined resection
should be considered.

Reference
Fig. 40.2 Red line shows planned plane of posterior dis- 1. Yun SS, Lee DS, Kim HJ. Hepatobiliary & pancreatic
section as shown in preoperative CT scan in posterior surgery. Seoul: koonja; 2015. p. 237–40.
RAMPS in which the tumor has penetrated the posterior
capsule of the pancreas. A left adrenal gland; K kidney; T Further Reading
tumor
Strasberg SM, Drebin JA, Linehan D. Radical ante-
grade modular pancreatosplenectomy. Surgery.
preserved and dissection begins in the ante- 2003;133:521–7.
rior plane of the adrenal gland, continued Strasberg SM, Fields R. Left-sided pancreatic cancer:
laterally, usually taking Gerota’s fascia. The distal pancreatectomy and its variants: radical ante-
superior and inferior attachments of the pan- grade modular pancreatosplenectomy and distal
pancreatectomy with celiac axis resection. Cancer J.
creas are divided as the dissection proceeds 2012;18(6):562–70.
to the left. The inferior mesenteric vein is Park HJ, Do You D, Choi DW, Heo JS, Choi SH. Role of
transected. Division of the several splenic radical antegrade modular pancreatosplenectomy for
ligaments is the last step in the procedure adenocarcinoma of the body and tail of the pancreas.
World J Surgery. 2014;38:86–193.
 Spleen-Preserving Distal
Pancreatectomy 41
Yong Hoon Kim

Abstract case, partial necrosis of the splenic parenchyma

may occur after surgery, but splenic infarction
Exposure to blood-borne antigens elicits
was reported in 1.9% of cases in a recent long-­
immune response of spleen primarily. Spleen
term follow-up series and gastric varices were
plays an important role in the patient’s immune
detected in 25% of patients [2]. However, no
system. Spleen preservation is beneficial to
cases of gastrointestinal bleeding or splenic
the patient in the absence of oncological con-
hypertrophy were reported. Rather, the operation
traindication for distal pancreatic resection.
duration is short; the bleeding is minor and asso-
However, because the splenic vessels are weak
ciated with few complications, which reduces the
and the pancreatic parenchyma carries several
length of hospital stay [3]. We will only discuss
short branches, it is easily damaged during
distal pancreatic resection that preserves the
surgery.
spleen and splenic vessel (artery and vein).
Keywords

Distal pancreatectomy · Spleen-preserving · 41.1.2 Definition

Splenic vessel
During distal pancreatic resection, the pancreatic
transection line may vary depending on the tumor
41.1 Introduction location but usually refers to resection in the
superior left portion of the pancreas at the junc-
41.1.1 Terminology tion of portal and superior mesenteric veins.

The two types of spleen-preserving distal pancre-

atectomy include conservation of the splenic 41.1.3 Indications
artery and vein, and the sacrifice of splenic ves-
sels. The blood supply to spleen is maintained by Pancreatic resection is indicated for benign
the remaining short gastric artery [1]. In the latter tumors requiring surgery, pancreatic cystic neo-
plasm, and borderline malignant tumors in the
body and tail of the pancreas without adjacent
Y. H. Kim (*) organ infiltration (Fig. 41.1).
Department of Surgery, Keimyung University School
of Medicine, Dongsan Medical Center,
Daegu City, South Korea

© Springer Nature Singapore Pte Ltd. 2023 267

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_41
268 Y. H. Kim

Hepatic artery proper

Left gastric artery

Celiac axis

Tumor Splenic artery

Splenic vein

IMV
Spleen

SMA

SMV

SVC Aorta

Fig. 41.1 Anatomical structure and blood vessels around the pancreas

41.2 Surgical Technique pancreatic head, body, and tail, and spleen. At
this time, dissection is performed carefully to
41.2.1 Incision prevent damage to the short gastric vessel and the
gastroepiploic arcade (Fig. 41.2a, b).
Laparotomy may be performed with an upper The proximal part is resected, followed by dis-
midline incision or a left subcostal incision, and a section toward the splenic hilum. Another method
lower midline incision or a right-side subcostal entails detaching the pancreatic tail from the
incision may be additionally performed depend- splenic hilum and dissecting it toward the proxi-
ing on the patient’s condition, the tumor location, mal part (from left to right) of the pancreas. There
and the anatomical structure. is a high possibility of damage to the small vascu-
lar branch of the spleen when the initial pancre-
atic parenchyma is separated from the spleen
41.2.2 Exposure of Pancreas (left-to-right dissection). Therefore, it is safe to
and Confirmation dissect it from the right to the left side.
of Pancreatic Tumor Location The normal pancreatic region to be excised is
selected proximally, and the peritoneum sur-
After exploration of the entire abdominal cavity, rounding the pancreas is separated from the
the gastrocolic ligament is separated and opened upper and lower pancreatic borders. Stay sutures
to ensure sufficient visibility to the posterior gas- are applied to both the upper and lower borders
tric wall and anterior pancreas to identify the of the pancreas. The pancreas is blunt dissected
41 Spleen-Preserving Distal Pancreatectomy 269

a b

Fig. 41.2 (a) Gastrocolic ligament is sufficiently separated to expose the anterior part of the pancreas (b) The trans-
verse colon from the spleen is separated and dropped down to secure the field of view

dorsally by lifting the supporting sutured pan- 41.2.3 Pancreatic Dissection

creas upwards until the splenic vein is confirmed.
The splenic vein runs parallel along the distal The umbilical tape is hung after deciding the
region deep inside the upper portion of the pan- expected pancreatic cutting area and tunneling
creatic parenchyma from the back of the pan- the back of the pancreas. A support stay suture is
creas. If it is difficult to identify the splenic vein, applied to the upper and lower portions of the
it is easier to examine the portal vein-splenic pancreas, and the pancreas is incised while pull-
vein junction, underneath the pancreatic neck, ing upward. The transection is usually initiated
and detached to the splenic hilum. The splenic with electrocautery, and the last incision is made
artery is usually located along the upper border using a knife around the main pancreatic duct for
of the pancreas. After the spleen artery and vein accurate identification (Fig. 41.3). In addition,
are separately taped with a vascular loop, the the pancreas may be cut using ultrasonic shears
pancreas can be excised and dissected to the dis- instead of electrocautery or it may be excised at
tal portion. once with a linear stapling device.

1. The gastrocolic ligament is separated, and the

transverse colon is dropped downwards to 41.2.4 Management
expose the anterior pancreatic surface. of the Pancreatic Remnant
2. Caution is needed to avoid damage to the gas-
troepiploic arcade. The most common complication after distal pan-
3. Blunt dissection and taped back of the pan- creatic resection is pancreatic fistula. Several
creas are followed by upper and lower stay methods have been reported to treat the remain-
suture. ing pancreatic stump after resection and to pre-
4. After the pancreas is transected, the dissection vent the leakage of pancreatic duct from the
proceeds while lifting from the right side to divided pancreas, but there is no way to consis-
the splenic hilum. When lifting the pancreas tently reduce the pancreatic fistula. In a meta-­
upward, caution is necessary to prevent tears analysis comparing hand-sewn ligation suture
in the branch of the short splenic vein by and automatic suture (staple) for treatment of
applying excessive force. pancreatic remnants after pancreatic resection,
270 Y. H. Kim

Fig. 41.3 The expected portion of the pancreatic cut is

placed on the U-tape and a support suture is applied on the Fig. 41.4 The remaining cut surface of the pancreas is
cutting surface closed with a non-absorbable suture in the form of a fish
mouth to prevent pancreatic fistula

no statistically significant difference was found

in the incidence of pancreatic fistula between the omentum, the small bowel, or the falciform
two methods. When the two methods were ligament of the liver.
­compared in a multicenter prospective compara- 4. Sealing with a fibrin sealant: After treating the
tive study conducted in a European group, no sig- cut surface with method A or B, the fibrin
nificant difference was found in the occurrence of sealant may be used additionally to prevent
pancreatic fistula between the two groups. Our pancreatic fistula [5].
institute prefers application of a fibrin sealant
after cutting with an automatic suture (staple) or
suture ligating the cut surface of the pancreatic 41.2.5 Pancreatic Detachment
duct. from the Splenic Vein

1. Direct ligation or suture of the main pancre- After the pancreas is transected, the dissection is
atic duct: When the pancreas is cut with a sur- performed by lifting the pancreas to the upper left
gical knife, the remaining cut surface is side. Small branches, usually from the splenic
interrupted with a mattress suture and sealed vein, are weak and often enter the pancreatic
in a fish-mouth form. At this time, it is impor- parenchyma briefly, which can lead to severe
tant to examine the main pancreatic duct and bleeding during the dissection. It is common to
ligate it separately (Fig. 41.4). ligate and separate both sides of a small vein
2. Using a linear stapling device: If the pancreas branch. However, if the branch is short and the
is relatively soft and not so thick, it is better space is narrow for clamping, the remaining side
to cut with an automatic suture device (sta- is ligated with a suture or a hemostatic clip ensur-
ple), because the stapling line tightly holds ing safe hemostasis of the pancreatic side excised
the cutting surface in a tight row. It can pre- with ultrasonic shears.
vent the leakage of microscopic pancreatic Vascular sutures may be performed using non-­
ducts. The self-sealing cartridge of appropri- absorbable monofilament 5-0 suture material if
ate height can be used according to the thick- there is bleeding from the venous branch during
ness of the pancreas, and the appropriate one dissection of the splenic vein. Dissection can be
can be selected based on the color of manu- performed from the proximal to the distal part
facture [4]. (spleen) until the pancreatic tail is separated from
3. Other methods include anastomosis of the the splenic hilum (Fig. 41.5). At this time, the
main pancreatic duct with jejunum, and cov- surgery is in the final stage. The surgeon should
ering the pancreatic stump with the greater be careful not to pull the pancreas excessively
41 Spleen-Preserving Distal Pancreatectomy 271

covered with the front of the pancreas to close the

open abdominal wall.
Immediately after surgery, the patient’s hemo-
dynamic status is monitored to ensure that there
is no rapid bleeding. The nature (color, viscosity,
amount of drainage) of the drainage catheter is
evaluated daily and the amylase level measured
Fig. 41.5 The pancreas is transected and raised from the to determine the occurrence of pancreatic fistula.
right to the left during the dissection, avoiding excessive
traction to prevent damage to the splenic vein branch
References
upward to prevent tearing of short gastric or left
gastroepiploic vessels and bleeding. It is a good 1. Warshaw AL. Conservation of the spleen with distal pan-
createctomy. Arch Surg. 1988;123(5):550–3. https://
practice to avoid mobilizing the spleen and lifting doi.org/10.1001/archsurg.1988.01400290032004.
it to the right, which can increase the risk of iat- PMID: 3358679
rogenic splenic injury. 2. Ferrone CR, Konstantinidis IT, Sahani DV, Wargo
JA, Fernandez-del Castillo C, Warshaw AL. Twenty-­
three years of the Warshaw operation for distal pan-
createctomy with preservation of the spleen. Ann
41.3 The Surgical Field of View Is Surg. 2011;253(6):1136–9. https://doi.org/10.1097/
Evaluated before SLA.0b013e318212c1e2. PMID: 21394008
Completing the Surgery 3. Jain G, Chakravartty S, Patel AG. Spleen-preserving
distal pancreatectomy with and without splenic ves-
and Post-Operative Patient sel ligation: a systematic review. HPB (Oxford).
Care 2013;15(6):403–10. https://doi.org/10.1111/
hpb.12003. Epub 2012 Dec 2. PMID: 23458666;
Following the pancreatic resection, a re-­ PMCID: PMC3664043
evaluation of bleeding in the surgical field is nec- 4. Tieftrunk E, Demir IE, Schorn S, Sargut M, Scheufele
F, Calavrezos L, Schirren R, Friess H, Ceyhan
essary, and if unclear, hemostasis should be GO. Pancreatic stump closure techniques and pan-
carefully performed via ligation and electrocau- creatic fistula formation after distal pancreatectomy:
tery. It is important to ensure that no bleeding meta-analysis and single-center experience. PLoS
One. 2018;13(6):e0197553. https://doi.org/10.1371/
occurs in the small branch of the preserved journal.pone.0197553. PMID: 29897920; PMCID:
splenic vein. After sufficiently washing the PMC5999073
abdominal cavity with physiological saline and 5. Wilson C, Robinson S, French J, White S. Strategies
confirming the absence of gauze on the back of to reduce pancreatic stump complications after open
or laparoscopic distal pancreatectomy. Surg Laparosc
the spleen or the back of the stomach, the closed Endosc Percutan Tech. 2014;24(2):109–17. https://
suction drain is placed around the remaining doi.org/10.1097/SLE.0b013e3182a2f07a. PMID:
­pancreatic stump. The stomach and omentum are 24686344
 Laparoscopic
Pancreaticoduodenectomy 42
Song Cheol Kim and Ki Byung Song

Abstract 42.1 Historical Background

During the past 25 years, the feasibility and
• Pancreaticoduodenectomy has been consid-
safety of minimally invasive pancreatic sur-
ered one of the most challenging abdominal
gery have been established progressively.
surgeries. Because of the complexity of the
Although laparoscopic pancreaticoduodenec-
techniques used, surgeons require more train-
tomy (LPD) is one of the most technically
ing time than in other abdominal surgeries, in
challenging procedures, it is safe, feasible,
order to gain adequate experience.
and oncologically acceptable when performed
• Gagner and Pomp were the first to describe
in a high-volume center. Studies have demon-
laparoscopic pancreaticoduodenectomy
strated the several advantages of minimally
(LPD) in 1994 [1]. During the first 10 years,
invasive approaches compared with the open
the progress of LPD was slow due to wide-
approach for pancreatic resection, namely,
spread controversy and opposition.
less blood loss, shorter hospital stay, and early
• Over the past 2 decades, advances in LPD
recovery. LPD requires long and steep learn-
have resulted in major improvements in peri-
ing curve.
operative and oncologic outcomes in high-­
volume centers [2, 3]. LPD represents a
Keywords
potential alternative to open approach follow-
Laparoscopic pancreaticoduodenectomy · ing the learning curve.
Pancreatic head tumor

42.2 Surgical Management

• Positioning and trocar placement

Supplementary Information The online version con-
tains supplementary material available at https://doi. The patient is placed in the supine posi-
org/10.1007/978-­981-­16-­1996-­0_42. tion. An anti-Trendelenburg (10–30°) is used
to expose the operation field. Two monitors
are placed at the sides of the operator and first
S. C. Kim (*) · K. B. Song
Division of Hepatobiliary and Pancreatic Surgery, assistant. The primary surgeon and the second
Department of Surgery, Asan Medical Center, assistant, who holds the laparoscope, stand to
University of Ulsan College of Medicine, the right of the patient. The first assistant and
Seoul, South Korea the scrub nurse are positioned to the left of the
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 273

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_42
274 S. C. Kim and K. B. Song

patient. Alternatively, a split-leg positioning coordination, which enhances performance

can be used for LPD. In this position, the oper- and surgical manipulation. Additional four
ator stands between the legs of the patient and trocars are placed under direct vision. Two to
the assistants stand on either side of the patient. three 5-mm trocars (one on the right flank for
Open technique is used to establish the pneu- the left hand of the surgeon and one to two on
moperitoneum using a 12-mm trocar on the the left flank for surgical assistance, if neces-
umbilicus. A 30° angled vision scope is used to sary) and two 12-mm trocars (one for the lapa-
visualize the deep portion. The trocar locations roscope and one on the umbilicus for the right
are shown in Fig. 42.1. Three-­dimensional hand of the surgeon) are employed. Abdominal
visualization improves image quality and pressure is maintained at 12 mmHg using car-
accuracy in spatial distance and hand–eye bon dioxide (CO2) gas insufflation. It is impor-

1st Asistant

Operator 5 mm

5 mm
5 mm
12 mm
12 mm

2nd Asistant Nurse

Fig. 42.1 Location of trocar for laparoscopic PD. Three tance) and two 12-mm trocars (one for the laparoscope
5-mm trocars (one on the right flank for the left hand of and one on the umbilicus for the right hand of the sur-
the surgeon and two on the left flank for surgical assis- geon) are employed. (PD, pancreaticoduodenectomy)
42 Laparoscopic Pancreaticoduodenectomy 275

tant to minimize accumulation of CO2 gas by ing better surgical view around the pancreatic
maintaining the abdominal inflation pressure head. The upper border of the pancreas is dis-
low, not more than 12 mmHg. sected to establish a triangular zone formed by
• Identification of the portal vein and division of the common hepatic artery, upper border of
the duodenum or stomach the pancreatic neck, and the gastroduodenal
Any abnormalities or metastasis in the entire artery (GDA) (Fig. 42.3). The GDA is ligated
abdomen is examined. The entire hepatic and at its origin and then divided with a vascular
peritoneal surfaces should be inspected. The staple load. The author recommends marking
gastrocolic omentum is dissected to allow entry this vessel as well using a clip. The PV tunnel
into the lesser sac. Intraoperative ultrasound is completed and gentle upward traction of the
may be used for further examination to identify isolated pancreas is applied using an umbilical
the location of the lesion. The portal vein (PV) is tape in preparation for pancreatic division.
identified at the inferior border of the pancreas • Mobilization of the right colon and duode-
by distally following the gastroepiploic vein num, and identification of the superior mesen-
(GEV) along its insertion into the SMV. The teric vein
GEV is clipped and divided at its entry into the The peritoneum of the hepatic flexure of
SMV. The anterior aspect of the retropancreatic the right colon is incised. The right colon is
segment of the PV/SMV is dissected, and a mobilized downward and to the left side of
tunnel is created (Fig. 42.2). The gastrohepatic the patient to fully expose the second and
omentum is opened to expose the hepatic artery third portions of the duodenum. The dissec-
coursing cephalad to the pancreas. The right tion between the mesocolon and the duode-
gastric artery is ligated using a metal clip and num/pancreatic head is continued along the
divided using a Harmonic scalpel. After divid- avascular surgical plane and is facilitated by
ing the branches of the right gastroepiploic the first assistant pulling the mesentery of the
vessels along the duodenum, the duodenum
is divided 2 cm distal to the pylorus using an
endoscopic linear stapler. Alternatively, resec-
tion of the gastric antrum can be performed
according to surgical preference or when an
adequate margin cannot be acquired. The stom-
ach is placed in the left upper abdomen, provid-

Fig. 42.3 Triangular zone. The common hepatic artery,

upper border of the pancreatic neck, and GDA form a tri-
angle for the tunnel behind the pancreatic neck. The trian-
Fig. 42.2 Identification of PV and SMV. The SMV is gular space is dissected to isolate the pancreas from the
identified at the inferior border of the pancreas and dis- PV (tunneling) and a gentle upward traction of the iso-
sected up to the retropancreatic PV. (PV, portal vein; lated pancreas is applied using a cotton tape in preparation
SMV, superior mesenteric vein) for pancreatic division (GDA, gastroduodenal artery)
276 S. C. Kim and K. B. Song

right colon toward the patient’s right lower exposed by dissecting the soft tissues and
­quadrant. The third and fourth portions of lymphatics using ultrasonic shears or mono-
the duodenum are mobilized (Kocher maneu- polar electrocautery.
ver), including the division of the ligament of • Division of the pancreatic neck
Treitz (Fig. 42.4). Dissection is continued to Suture ligation of the longitudinal arter-
the left of the aorta and up to the origin of the ies coursing within the parenchyma along the
superior mesenteric artery (SMA). The third superior and inferior border of the pancreatic
and fourth portions of the duodenum must be neck can be used to control bleeding from the
fully exposed prior to the division of the mes- cut surface during pancreatic transection. We
entery to the duodenum. prefer to use ultrasonic shears to divide the
• Dissection of the porta hepatis pancreatic parenchyma to minimize bleeding.
Cholecystectomy is performed. The lym- The pancreatic duct is resected using lapa-
phatic dissection occurs distally from the roscopic scissors (METZENBAUM ENDO)
divided origin of the GDA until the bifurca- and identified (Fig. 42.5). A frozen tissue sec-
tion of the proper hepatic artery. Careful dis- tion can be obtained from the margin of the
section of the bile duct should be performed pancreas. The remaining pancreatic stump
to avoid injury to the accessory or replaced is further dissected to provide a mobility of
hepatic artery from the SMA traveling pos- 1–2 cm necessary to invaginate the pancreas
terior to the common bile duct or the low- into the jejunum for the pancreaticojejunos-
lying right hepatic artery traversing anterior tomy (Fig. 42.6).
to the bile duct. Preoperative review of the • Transection of the proximal jejunum
CT scan and careful inspection before divi- The jejunal mesentery, 10–15 cm distal
sion of the bile duct is crucial to avoid unex- to the ligament of Treitz, is divided between
pected injury to the hepatic artery because vascular arcades and the mesenteric vessels
palpation of the porta hepatis is impossible are ligated. The jejunum is transected with an
in laparoscopic surgery. The common bile endoscopic linear gastrointestinal stapler. This
duct is divided. The proximal duct is con- procedure is performed in its original position
trolled with a bulldog clamp. The distal (division of the jejunum and mesentery prior
duct is ligated to prevent contamination and to pulling the jejunum into the right side).
facilitate hemostasis. The PV is now fully • Division between the superior mesenteric
artery (SMA) and the uncinate process.
This step is the most technically difficult
part of the procedure and also the most criti-

Fig. 42.4 Mobilization of the retroperitoneal duodenum.

Kocher maneuver involves the left renal vein and aorta.
Careful traction of the duodenum is essential to prevent
duodenal perforation. A full mobilization of the retroperi-
toneal duodenum facilitates the separation of duodenum
from the root of the mesentery. (IVC, inferior vena cava;
SMA, superior mesenteric artery; LRV, left renal vein;
DJJ, duodenojejunal junction) Fig. 42.5 Identification of pancreatic duct
42 Laparoscopic Pancreaticoduodenectomy 277

adenocarcinoma. However, in case of pancre-

atic ductal adenocarcinoma, a clear dissection
of the neurolymphatic soft tissues of the right
side of the SMA is needed to obtain a margin-­
negative specimen (Fig. 42.8). The specimen
is placed in a specimen bag and retrieved
at the end of procedure, either through the
2–3 cm extension of the umbilical port or a
separate incision.
• Reconstruction
Pancreatojejunostomy (PJ) was performed
using a double-layered, end-to-side, duct-to-
mucosa method using laparoscopic sutures. PJ
Fig. 42.6 Mobilizing the pancreatic remnant. The involving the first layer of the anastomosis
remaining pancreatic stump is mobilized by 1–2 cm to
facilitate invagination of the pancreas into the jejunum for was performed between the posterior wall of
the pancreaticojejunostomy the pancreas and the seromuscular layer of the
jejunum with a running suture (non-absorb-
able 4-0). The second layer was sutured
cal in terms of obtaining tumor-free margins.
Elevation of the specimen reveals detailed fea-
tures of the remaining attachments, including
tributaries of the PV or SMV. The first jeju-
nal vein and pancreaticoduodenal veins drain
into the portomesenteric vein (Fig. 42.7). To
facilitate the dissection and control any unex-
pected bleeding from the PV or SMV, vessel
loops are applied to the PV and SMV, respec-
tively, immediately above the splenic vein
and the first jejunal vein. Traction with vessel
loops enables clear visualization of the neu-
rolymphatic soft tissues around the SMA. We
prefer an upward dissection to expose the Fig. 42.7 Lateral and anterior retraction of the specimen
venous branches more effectively than the is useful to identify the first jejunal vein and pancreatico-
duodenal veins (PDV) draining into the portomesenteric
downward approach. Upward traction of the vein
SMV using vessel loops and caudal traction of
the specimen can facilitate the identification
of posterior venous tributaries draining from
the uncinate process into the first jejunal vein
(two or three veins), which can be divided
with clips and a Harmonic scalpel. The soft
tissue near the SMA should then be dissected
to identify one to two inferior pancreaticoduo-
denal arteries. The remaining dissection of the
soft tissue between the SMA and the uncinate
should be dictated by the oncologic status.
Fig. 42.8 A clear dissection of the neurolymphatic soft
The dissection can be performed near the tissues of the right side of the SMA is needed to obtain a
uncinate process without risk of injury to the margin-negative pancreatic cancer specimen (SMA, supe-
SMA in diseases other than pancreatic ductal rior mesenteric artery)
278 S. C. Kim and K. B. Song

between the posterior wall of the main pancre- interrupted or continuous suturing at the anterior
atic duct and the full layer of the jejunum with wall. Duodenojejunostomy or gastrojejunostomy
interrupted suture (non-­ absorbable 4-0). A with Braun anastomosis was carried out intracor-
hole was created in the jejunum using the poreally or extracorporeally via the specimen
electronic coagulator and a polyethylene extraction site. Two to three closed suction drains
internal stent was temporarily inserted into the were placed at the superior and inferior borders
main pancreatic duct. Duct-to-­ mucosa PJ of the pancreatojejunostomy site.
entailed more than four stitches of sutures
(absorbable 5-0). The third layer of the anasto-
mosis was sutured between the anterior wall References
of the main pancreatic duct and the anterior
1. Gagner M, Pomp A. Laparoscopic pylorus-­
wall of the jejunum with a running suture preserving pancreatoduodenectomy. Surg Endosc.
(non-­absorbable 4-0). The fourth layer was 1994;8(5):408–10.
sutured between the anterior wall of the pan- 2. Conrad C, Basso V, Passot G, Zorzi D, Li L, Chen HC,
creatic stump and the seromuscular layer of Fuks D, Gayet B. Comparable long-term oncologic
outcomes of laparoscopic versus open pancreaticodu-
the jejunum with interrupted sutures (non- odenectomy for adenocarcinoma: a propensity score
absorbable 4-0). weighting analysis. Surg Endosc. 2017;31(10):3970–8.
3. Song KB, Kim SC, Hwang DW, Lee JH, Lee DJ,
End-to-side hepaticojejunostomy was per- Lee JW, Park KM, Lee YJ. Matched case-control
analysis comparing laparoscopic and open pylorus-­
formed via laparoscopic continuous suturing preserving Pancreaticoduodenectomy in patients with
(non-absorbable 5-0) at the posterior wall and Periampullary tumors. Ann Surg. 2015;262(1):146–55.
 Laparoscopic Distal
Pancreatectomy 43
Chang Moo Kang

Abstract approach for minimally invasive distal

pancreatectomy.
Laparoscopic distal pancreatectomy (LPD)
is one of the potential options for benign and
Keywords
low-grade malignant tumors in the left-sided
pancreas. Many experiences and a recent Laparoscopic · Robotic · Distal pancreatec-
prospective randomized control study (RCT) tomy · Spleen · Pancreatic cancer
have confirmed that LPD is safe, effective,
and provide the benefit of minimally inva-
sive surgery. Recently, with advancements
43.1 Introduction
in the laparoscopic technique, LPD is being
actively applied even to resectable left-sided
Adaptation of laparoscopic surgery for pancre-
pancreatic cancer, and it has shown compa-
atic resection was late compared with other types
rable perioperative and long-term oncologic
of general surgery [1]. Considering the limita-
outcomes to open surgery. In addition, the
tions of laparoscopic surgery, the pancreas is not
robotic surgical system was introduced and
easy to access laparoscopically, because of its
is currently available. Surgeons could take
location in the retroperitoneal space. In particu-
advantage of this system in well-selected
lar, the pancreas is supplied with abundant blood
cases. In this chapter, detailed surgical tech-
from major blood vessels. Therefore, even a
niques for LPD are discussed with special
small disruption of tributary vessels around the
clinical issues, such as spleen-preserving
pancreas results in severe bleeding, obscuring the
technique, clinical application to left-sided
surgical field. In addition, postoperative pancre-
pancreatic cancer, and an innovative robotic
atic fistula (POPF) [2] is associated with fatal
complications for the patient. However, accumu-
Supplementary Information The online version con- lating laparoscopic surgical experience, develop-
tains supplementary material available at https://doi. ment of new surgical techniques, energy devices,
org/10.1007/978-­981-­16-­1996-­0_43. and advances in perioperative patient care have
contributed to the safety and effectiveness of lap-
C. M. Kang (*) aroscopic pancreatic resection.
Division of Hepatobiliary and Pancreatic Surgery, Laparoscopic distal pancreatectomy (LDP)
Department of Surgery, Yonsei University College of was first introduced in 1994 by Soper et al. [3],
Medicine, Seoul, South Korea who reported successful LDP in pig pancreas. In
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 279

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_43
280 C. M. Kang

1996, Cuschieri [4] and Gagner [5] reported 5 fully and safely evaluated according to the opera-
and 12 patients with LDP, respectively, suggest- tor’s experience and technique.
ing the technical feasibility and safety of LDP. In In particular, rather than performing LDP for
Korea, Yoon, et al. [6] first performed LDP in all patients who have resectable pancreatic can-
2001. Min et al. [7] reported the first two cases of cer, it is more reasonable to perform selective,
LDP by conserving both splenic artery and vein minimally invasive DP in patients with left-sided
in 2003, opening the door to function-preserving pancreatic cancer to improve quality of life and
minimally invasive pancreatic surgery. long-term oncologic safety. Accordingly, clini-
Many recent clinical investigations showed cally significant Yonsei criteria were proposed
that LDP is effective and appropriate in treating [11]. Yonsei criteria are based on the concept of
benign and low-grade malignant tumors of the appropriate tumor conditions to achieve blood-
pancreas, compared with open DP [8]. Moreover, less and margin-negative resection using a lapa-
short-term and long-term oncologic outcomes of roscopic approach in light of past surgical
LDP were not inferior to those of open DP even experience of resected distal pancreatic cancer.
in left-sided pancreatic cancer [9]. Especially, The criteria include the following: (1) tumors
rapid recovery after LDP potentially increases confined to pancreas; (2) intact fascia layer of
the possibility of non-delayed postoperative posterior pancreas; and (3) 1–2 cm apart from the
adjuvant chemotherapy. Recently, a multicenter, origin of celiac and splenic arteries. In fact, the
prospective randomized control study was per- Yonsei criteria were cited to include tumor condi-
formed to compare LDP with open DP. In cases tions for pancreatic cancer in the previous multi-
involving well-selected pancreatic tumors lim- center prospective randomized clinical trials
ited to the pancreas, Rooij, et al. [10] reported [10]. Accordingly, the indications for LDP in
that minimally invasive DP significantly reduced pancreatic cancer may be gradually expanded
the time leading to functional recovery, reducing following advances in surgeons’ experience and
delayed gastric emptying without increasing techniques,
costs, and maintaining high quality of life.
Therefore, LDP is currently established as a stan-
dard technique. In this chapter, technical aspects 43.3 Preoperative Factors
of LDP with special clinical considerations will
be discussed. Similar to other surgeries, the following three
factors should be considered before performing
LDP.
43.2 Indications

LDP is indicated not only for benign and low-­ 43.3.1 Patient Assessment
grade malignant tumors of left-sided pancreas
that can be treated via standard surgical It is critical to evaluate patients preoperatively
approaches, but also well-selected left-sided pan- and understand their physical and functional
creatic cancer (see below). However, large tumors capacity. Especially, it is not uncommon that
in contact with major blood vessels or associated LDP entails prolonged operation and bleeding.
with multiple organs may lead to intraoperative Long-term pneumoperitoneum can result in
complications such as bleeding of major blood adverse cardiopulmonary effects. In addition, in
vessels and peripheral organ damage or inevita- preparation for lower extremity venous thrombo-
ble intraoperative conversion to open surgery. sis and pulmonary embolism due to stagnant
Therefore, the indication for LDP should be care- venous blood in the lower extremity during sur-
43 Laparoscopic Distal Pancreatectomy 281

gery, a low-molecular heparin is considered dur- Table 43.1 Preoperative factors determining LDP
ing surgery and within 48 h after surgery. When Tumor location
concomitant splenectomy is highly expected,  • Potential division line of the pancreas (neck/body/
tail).
vaccination to prevent OPSI should be consid-
Feasibility of spleen preservation
ered at least 7–10 days before surgery. In particu-  • Appropriate for splenic vessel conserving.
lar, as the number of elderly patients is increasing,  • Appropriate for splenic vessel sacrificing
it is necessary to determine the appropriate surgi- (Warshaw’s procedure)?
cal extent and operation time, considering the Combined splenectomy
 • Preoperative vaccination and schedule of elective
tumor biology and the physiological capacity of surgery
the elderly patients.  • Feasibility of robotic single-site plus ONE-port
approach
Malignancy
43.3.2 Tumor Assessment  • Resectable within Yonsei criteria/ out of Yonsei
criteria
 • Open vs. laparoscopic approach
Before surgery, patients usually undergo a num-  • Combined resection of left-adrenal gland, colon,
ber of radiological examinations for accurate pre- and stomach
operative diagnosis, and decision-making  • Perigastric collateral vessels
regarding the extent of surgical resection. It is
thought that preoperative abdominal computed
tomography (CT) facilitates determination of the 43.4 Operative Technique
tumor location relative to blood vessels and other
organs. Based on the CT images, the surgeon can 43.4.1 Patient Posture
preoperatively estimate whether the pancreatic
mass is malignant, the location of the pancreatic Surgeons may prefer the right lateral decubitus
mass, running course of the major blood vessels position when performing LDP. However, the
(splenic artery and vein), the anatomic relation- author recommends a supine position for the fol-
ship between the tumor and the splenic vessels, lowing reasons.
or surrounding organs, such as stomach, colon, or The preparation for supine position is simple.
left kidney/adrenal gland, and even between the Supine position does not waste unnecessary time
pancreatic tail and spleen hilum, which are essen- and energy before surgery. Right lateral decubitus
tial factors in surgical design. is a useful method for securing the surgical field
for left-sided pancreas using gravity, but this con-
dition differs from the open surgery. Therefore,
43.3.3 Planning Operation even in the case of laparoscopic surgery, based on
the supine posture, the surgeon can operate in the
Surgeons need to develop their own strategies for same surgical field and under conditions similar
LDP based on preoperative imaging studies, and to open surgery. Therefore, even a beginner may
prepare several alternative options in the event of be quick to adapt to laparoscopic surgery.
unexpected operative findings. A personal check- Surgeons cannot access the whole pancreas, espe-
list when preparing for elective LDP in clinical cially pancreatic neck and head area in a patient
practice is presented in Table 43.1. The appropri- with right lateral decubitus, because omentum
ate surgical approach should be based on patients’ and small intestine fall into dependent position
safety and surgical merit depending on the tumor due to gravity, resulting in hidden duodenum and
location, biological characteristics, and anatomi- proximal pancreatic head area. Therefore, the
cal relationship between tumor and surrounding supine position can resolve all these issues, ensur-
vascular structure. ing adequate operation field and ensuring dissec-
282 C. M. Kang

tion of SMV-SV-PV confluence and pancreatic number of trocars can be adjusted according to
neck, even in the pancreaticoduodenal unit. A the tumor location and size. For example, in
supine position can expand the surgical indication case of pancreatic tail lesions, a minimum of
of LDP, even in well-­selected cases of distal pan- one left-­sided 5-mm and another one 12-mm
creatic cancer, and laparoscopic pancreaticoduo- trocar are used for LDP with concomitant sple-
denectomy (LPD). It is easy to switch rapidly to nectomy (Fig. 43.2a). However, when the tumor
open conversion during laparoscopic surgery. In is in the neck or near the proximal body of the
addition, in the right lateral decubitus position, pancreas, an additional right-sided 5-mm and
spleen preservation may be difficult because the another 12-mm trocar need to be inserted for
spleen is pressed against the pancreatic tail due to effective surgical manipulation (Fig. 43.2b).
the weight of the spleen and the spleen is directed Therefore, the trocar position of LPD can be
toward the abdominal cavity along with the pan- adjusted according to the patient’s condition,
creatic tail. However, supine position facilitates operator’s experience, and tumor location.
spleen-­preserving procedures because spleen is In the past, small trocars (5 mm) and a mini-
located in the dependent position. mum number of trocars (3 trocars including
When the patient is supine, the patient operat- umbilical site trocar for laparoscope) were pre-
ing table may be adjusted (for example, head-­ ferred. However, larger trocars (12 mm) have
side up or left-side up) to create appropriate been actively used recently. If it is properly
surgical field for LDP. Although some surgeons applied, (1) the access angle of laparoscopic
may stand between the legs of the patient, the working instruments can be adjusted as needed
author performs the operation on the right side of by changing the position of laparoscopic cam-
the patient. A typical operating room layout for era, and (2) active laparoscopy is feasible while
LDP is shown in Fig. 43.1. inserting the gauze into abdominal cavity (via
12-mm trocars) under direct laparoscopic
vision. In addition, (3) advanced laparoscopic
43.4.2 Trocar Placement instruments are appropriate for larger trocars.

In general, two 5-mm trocars and three 12-mm

trocars are used. However, the location and the 43.4.3 Access to Pancreas

Access to pancreas is similar in open and lapa-

roscopic surgery. With the stomach lifted, the
division of gastrocolic ligament with an energy
Assistant device (ultrasonic shears or vessel sealer) can
Operator
create surgical access to the whole pancreas
from the pancreas body to the tail (Fig. 43.3).
When planning for concomitant splenectomy,
gastrosplenic ligament should be divided in
this stage. When planning for spleen-preserv-
ing DP, gastrosplenic ligament need to be con-
served briefly because splenic vessel-sacrificing
Scopist Scrub
­spleen-­preserving DP (so-called, Warshaw’s
procedure) can be selected when splenic vessel-­
conserving DP procedure is difficult and impos-
sible due to chronic inflammation and frequent
bleeding.
Fig. 43.1 Patient posture and OR setup for LDP
43 Laparoscopic Distal Pancreatectomy 283

a b

Laparoscopic approach Laparoscopic approach

Fig. 43.2 Trocar placement in LDP. (a) In case of pan- These configurations of trocar placement are universal for
creatic tail lesion with concomitant splenectomy (b) In all standard pancreatic resections. Trocar placement can
case of division of pancreatic neck or proximal body of be adjusted according to the patient’s condition (body
the pancreas. Please note the right flank-sided trocar. shape, operator’s experience, and tumor location)

pancreatic fistula. Crushing of the pancreas dur-

ing endo-GIA may result in POPF. Therefore, it
is recommended that surgeons should slow down
the firing time in endo-GIA.
In addition, vascular endo-GIA reduced POPF
[15]. However, this author divides the pancreas
via endo-GIA with staple size ranging from 3 to
3.5–4 mm, which is appropriate for medium or
thick tissue.

43.4.4.2 Ultrasonic Sheers

Fig. 43.3 Division of gastrocolic ligament to access to
In some cases, the pancreas can be divided using
pancreas an ultrasonic sheer [16], especially, when there is
insufficient space between pancreas and splenic
43.4.4 Pancreatic Division vessels to use an endo-GIA, or endo-GIA cannot
be closed because the pancreas is hard and thick.
43.4.4.1 Endo-GIA Stapler When pancreas is divided by ultrasonic sheers,
Studies reported no statistical difference in post- the author closes the cut pancreatic surface with
operative outcomes between manual resection of sutures as much as possible before the operation
the pancreas and surgical stapling in DP [12]. As is complete. In addition, a few studies demon-
a result, laparoscopic endo-GIA is widely used strated the feasibility and safety of pancreatic
for LDP. resection using other energy devices [17], but the
According to recent clinical studies, pancre- effectiveness of this surgical technique should be
atic thickness [13] and firing time [14] of endo-­ carefully evaluated in the future based on scien-
GIA are a challenge in reducing postoperative tific evidence.
284 C. M. Kang

43.4.5 Vascular Control 43.4.6 Surgical Design

43.4.5.1 Splenic Artery Three types of pancreatic resection are consid-

Usually, the splenic artery is carefully dissected, ered according to potential pancreatic division
isolated, and divided with several laparoscopic line for LDP.
clips. However, in rare cases, the splenic artery
may be crushed during the application of surgical 43.4.6.1 50% > Distal
clips, leading to critical outcomes. The safety of Pancreatectomy: Modified
the surgical procedure is enhanced with a laparo- Lasso Technique
scopic tie followed by laparoscopic clips. Vascular Regardless of open or laparoscopic LDP, both
endo-GIA for the treatment of the splenic artery is splenic vessels are individually dissected, iso-
a good alternative (Fig. 43.4). lated, ligated, and divided in the conventional
approach, followed by pancreatic division
43.4.5.2 Splenic Vein (Fig. 43.7a). However, this approach is a little
The splenic vein can be simply ligated and treated complicated and can be difficult especially in
with several clips, or vascular endo-­GIA. However, chronic pancreatitis.
this author usually applies surgical clips following
a laparoscopic tie (Fig. 43.5).

43.4.5.3 Small Tributary Vessels

Careful dissection of the small blood vessels running
into the pancreas around the splenic artery and the
splenic veins is followed by control with small clips
and scissors, or energy devices with small clips on
the capillaries of the splenic artery or splenic vein
(Fig. 43.6). These capillaries can also be simply
treated with a vessel-sealing energy device [18]. The
treatment approach can be individualized. Fig. 43.5 Splenic vein control

a b

Fig. 43.4 Splenic artery control using vascular stapler. Vascular stapler is applied (a), Note stapled line (white arrow)
after division of SA (b) CAH common hepatic artery, SA splenic artery
43 Laparoscopic Distal Pancreatectomy 285

Therefore, to facilitate LDP, Velanovich [19] splenic artery ligation either by clips or by lapa-
introduced the “lasso” technique. In brief, when roscopic tie is conducted first before applying
LDP is performed, the distal pancreas with both endo-GIA to pancreaticosplenic ligament in lapa-
splenic vessels (splenic artery and vein) is lifted roscopic splenectomy in an effort to enhance pro-
altogether from the retroperitoneum using a cedural safety.
Penrose drain. The pancreas and both the splenic It is true that the “lasso” technique in LPD is
vessels are divided once via endo-GIA very simple and quite easy; however, the original
(Fig. 43.7b). It was argued that it was technically “lasso” technique may also carry a potential risk
easy and available for LDP, so that the potential of bleeding-related complications due to the sta-
indications for LDP will be expanded. However, pled splenic artery, based on the author’s personal
no further follow-up studies have been published experience involving laparoscopic splenectomy.
since then. Therefore, splenic artery control using either a tie
In fact, the author once used “simply” endo-­ or clips is always completed before the original
GIA to control pancreaticosplenic ligament in lasso technique is performed (modified lasso
laparoscopic splenectomy [20]. As expected, sur- technique, Fig. 43.7c). Recently, Kawasaki and
gical procedure is very simple, but one patient Kang, et al. [21] reported that this modified lasso
experienced severe postoperative bleeding imme- technique had favorable effects on the operation
diately after surgery and managed via interven- time, intraoperative bleeding, postoperative mor-
tional radiologic coil embolization. Since then, bidity rate, and the length of the postoperative
hospital stay, suggesting that the modified lasso
technique is simple, safe, and effective in LDP.

43.4.6.2 70% Distal Pancreatectomy:

“Subtotal (Extended)” Distal
Pancreatosplenectomy
When pancreatic lesion is located on the pancre-
atic neck or in the proximal pancreatic body, the
pancreatic neck above the SMV-SV-PV conflu-
ence is divided and the distal portion of the
­pancreas (subtotal/ extended distal pancreatec-
tomy) is considered. The division of pancreatic
Fig. 43.6 Control of small tributaries from splenic neck laparoscopically has clinical implications.
vessels First, it is possible to extend the indications of

a b c

Fig. 43.7 Surgical concept of modified lasso technique in laparoscopic DPS (a) Usual technique for distal pancreatec-
tomy. (b) Lasso technique. (c) Modified lasso technique
286 C. M. Kang

LDP. Second, it is a basic technique for perform-

ing LPD or central pancreatectomy.
The space between the pancreatic neck and
the SMV-SV-PV confluence is generally known
as avascular plane, but very rarely, small blood
vessels enter directly from the pancreas into
venous confluence, suggesting the need for cau-
tion. Although the preferences of every surgeon
for dissection of pancreatic neck may differ, the
following technique will guide surgeons to iso-
late the pancreatic neck safely and effectively.
Fig. 43.9 A window between pancreatic neck and SMV-­
SV-­PV confluence
• Dissection of upper part of the pancreatic neck
first can be helpful. Soft tissue between the
common hepatic artery and upper part of the creatic neck portion is ready. At this moment, if
pancreatic neck portion can be carefully dis- not careful, the common hepatic artery may be
sected to identify the portal vein (PV) at the encircled with pancreatic neck together and
bottom of this space (Fig. 43.8). divided with pancreatic neck. Therefore, dissec-
• Carefully dissection following the right gas- tion of the upper part of the pancreatic neck por-
troepiploic vein is essential to locate the part tion to identify the PV before creating the window
of superior mesenteric vein (SMV). between pancreatic neck and venous confluence
• In some cases, the SMV can be found directly will facilitate pancreatic neck encircling.
at the lower pancreatic neck by estimating the In addition, when dissecting pancreatic neck,
running course of SMV based on the location small tributary vessels connecting pancreas with
of PV, which was previously located at the SV, SMV, or SMA should be controlled using
upper part of pancreatic neck. clips in the large blood vessels, but not on the
pancreatic side. Most of the blood vessels in the
Once SMV is found, the area between the pan- pancreatic side can be controlled with an energy
creatic neck and the SMV-SV-PV confluence rep- device without clips. Endo-GIA may be difficult
resents an avascular plane (as mentioned above). for division of the pancreas due to the use of
Blunt dissection can be used to create a window some clips on the pancreatic side to control small
between pancreatic neck and SMV-SV-PV con- tributary vessels. These small clips may not be
fluence (Fig. 43.9) and hang the pancreatic neck allowed to securely close the endo-GIA during
covered with nylon tape. The division of the pan- the division of the pancreas.
The splenic artery and vein are safely ligated
using a laparoscopic tie first, followed by clips
when controlling the splenic vessels in 70%
LDP. Vascular endo-GIA application to control
splenic vessels is also an alternative option, espe-
cially in splenic artery (Figs. 43.4 and 43.5).
When the pancreas is detached from the perito-
neum, it does not matter if the inferior mesenteric
vein (IMV) enters the SMV, but if it enters the
SV, the IMV must be ligated and divided during
pancreatic resection.
In most benign or low-grade malignant tumors
Fig. 43.8 Laparoscopic dissection around upper part of located in the neck or proximal body of the
the pancreatic neck pancreas, function-preserving pancreatectomy
43 Laparoscopic Distal Pancreatectomy 287

(spleen-preserving procedures or limited pancre- techniques. Particularly, during pancreati-

atectomy, such as central pancreatectomy) is desir- tis or large tumors in wide contact with the
able. The application of laparoscopic radical DPS splenic vessels, it is often necessary to com-
in pancreatic cancer will be discussed briefly later. bine splenectomy due to frequent and severe
bleeding during the spleen-preserving pro-
43.4.6.3 50% Distal Pancreatectomy cedure. Recently, minimally invasive SVC-
This surgical extent is thought to be one of the SpDP can be performed effectively before
most difficult surgical designs. During 50% distal using a special energy device or robotic sur-
pancreatectomy, the origin of splenic artery needs gical system.
to be dissected first, but is not that easy because 2. Splenic vessel sacrificing
of several reasons. First, the origin of splenic In 1988, Warshaw introduced alternative
artery is usually behind the pancreas or embed- spleen-preservation technique, the so-called
ded in the pancreas. Second, neural tissue covers Warshaw procedure, in which splenic vessel
the origin of the splenic artery. These two factors sacrificing (SVS, segmental excision of
interfere with the dissection of splenic artery in splenic vessels with resected distal pan-
the modified lasso technique. In addition, the creas) SpDP was performed to increase the
potential line of division of the pancreas is wide technical feasibility of SpDP. As mentioned
and thick in the pancreas, resulting in frequent briefly above. However, the SVC procedure
POPF. Therefore, technically, for 50% distal pan- is technically challenging or even impossi-
createctomy, the general approach might be simi- ble in the presence of chronic pancreatitis.
lar to subtotal distal pancreatectomy. In this scenario, segmental resection of both
splenic artery and vein with distal pancreas
are alternative options for spleen preserva-
43.4.7 Spleen-Preserving Procedure tion. As a result, the spleen blood supply is
facilitated via short gastric vessels and left
The role of spleen is still controversial in adult gastroepiploic artery instead of excised
patients. Spleen is the largest immunologic organ main splenic artery and vein. Subsequently,
in our body. In the past, splenectomy was per- this procedure may involve two issues to be
formed during distal pancreatectomy for technical addressed.
convenience due to anatomical intimacy between • The substantial risk of spleen infarction
the pancreatic tail and the spleen. As the role of the after surgery: In the original article pub-
spleen is established [22], the frequency of spleen- lished by Warshaw [23], 4% (1 out of 25)
preserving distal pancreatectomy (SpDP) has required additional splenectomy due to
increased recently. The two methods to preserve spleen abscess following spleen infarction,
the spleen to date are as follows. limiting the application of this procedure
in the case of a large spleen.
1. Splenic vessel conserving • There may be a risk of gastrointestinal bleed-
Since the splenic vessels (splenic artery ing from the perigastric collateral vessels
and vein) anatomically supply blood to the due to impaired venous circulation via exci-
spleen and pancreas simultaneously, splenic sion of splenic vein. However, based on
vessel conservation (SVC) may facilitate 23 years of experience of the Warshaw group
spleen-preserving distal pancreatectomy [24], only 3 (1.9%) of the 158 patients in the
(SpDP). However, it is not easy to con- Warshaw study underwent additional sple-
trol individual small blood vessels from nectomy due to splenic infarction. In addi-
the splenic vessels using a laparoscopic tion, among 65 patients, only 16 patients
approach. This technique usually requires (25%) carried perigastric collateral veins,
a lot of time, effort, and advanced surgical but no clinical gastrointestinal bleeding or
288 C. M. Kang

splenic hypertension was noted, suggesting 43.6 Intraoperative Peritoneal

that the operation was a safe procedure. Drainage

Surgical drains are frequently used in LDP to

43.5 Methods to Prevent POPF evacuate blood, pancreatic juice, lymphatic fluid,
after Distal Pancreatectomy and small necrotic debris after surgery. However,
it should be balanced with the potential risk of
Several studies demonstrating reduced POPF fol- ascending infection. Several studies [40, 41]
lowing DP are summarized (Table 43.2). Based found no significant differences in the incidence
on the studies, in the era of LDP, the application of POPF compared with DP with and without a
of PGA and glue [25], perioperative IV hydrocor- surgical drain. A prospective, randomized multi-
tisone [26], and pasireotide [27] is recommended center trial of distal pancreatectomy with and
to reduce POPF following distal pancreatectomy. without routine intraperitoneal drainage was per-

Table 43.2 Recent RCTs to investigate surgical approach to reduce POPF following DP
Authors, Year Intervention N POPF (%) p-value
Kondo, 2018 [28] Reinforced stapler 61 16.3
Bare stapler 61 27.1 0.15
Cuncha, 2015 [29] TachoSil® 135 41(30.6)
Control 135 33(24.3) 0.279
Park, 2016 [30] TachoSil® 48 11(22.9)
Control 53 15(28.3) 0.536
Jang,2017 [25] PGA (Neoveil®) 44 5(11.4)
Control 53 15(28.3) 0.04
Shubert, 2016 [31] SIMGUARD® 32 4(12.5)
TISSELINK® 35 8(22.9) 0.35
Kawai, 2016 [32] PJ 62 24 (38.7)
Stapler closure 61 23 (37.7) 0.332
Hassenpfulg, 2016 [33] Tres ligament patch 76 17(22.4)
Control 76 25(32.9) 0.1468
Montorsi, 2012 [34] TachoSil® 145 12(9)
Control 130 18(14) 0.139
Carter, 2013 [35] Falciform ligament patch + glue 50 9(18)
Control* 51 9(18) 1
Frozanpor, 2012 [36] Preoperative transpapillary pancreatic stent 29 11(42.3)
Control 29 6(22.2) 0.122
Diener, 2011 [37] Stapler 221 24(43)
Hand-sewn closure 229 16(33) 0.27
Suc, 2003 [38] Fibrin glue occlusion 24 4
Control 20 3 >0.05
Uemura, 2017 [39] PG 36 7(19.4)
Control (hand-sewn) 37 7(18.9) 1
Antila, 2019 [26] Hydrocortisone, iv 17 1(6)
Control 14 6(43) 0.028
Allen, 2014 [27] Pasireotide, iv 41 (7)
Control 39 (23) 0.006
43 Laparoscopic Distal Pancreatectomy 289

formed [42]. It was noted that about 44% of the associated with inflammation act as cancer
patients underwent LDP (229 out of 528 enrolled progressing factor [45].
patients). No statistical differences were found in • Possible association with increased use of
terms of POPF and mortality, suggesting that postoperative adjuvant chemotherapy due to
clinical outcomes are comparable in DP with or early fast recovery [46].
without routine intraperitoneal drainage.
However, early drain removal strategy is a practi- It is still controversial, but laparoscopic radi-
cal and reasonable approach after pancreatec- cal distal pancreatectomy in well-selected pan-
tomy. Further studies are needed. creatic cancer is technically feasible and
ontologically safe. Lee, and Kang et al. [47]
recently reported long-term oncologic outcomes
43.7 Special Consideration of LDP in left-sided pancreatic cancer compara-
ble to those of open DP. In addition, a recent sys-
43.7.1 The Role of Spleen in Adult tematic review and meta-analysis investigated 21
Patients studies with 11,246 patients who underwent DP
for pancreatic ductal adenocarcinoma (PDAC).
In the past, Shoup et al. [22] reported the poten- They concluded that in patients with PDAC,
tial role of spleen in distal pancreatectomy. MIDP is associated with comparable survival
Splenic preservation was strongly recommended (hazard ratio 0.86; 95% confidence interval (CI)
because it decreased perioperative infectious 0.73–1.01; p = 0.06), R0 resection (odds ratio
complications, reduced the rate of severe compli- (OR) 1.24; 95% CI 0.97–1.58; p = 0.09), and use
cations, and decreased the length of hospital stay. of adjuvant chemotherapy (OR 1.07; 95% CI
However, this conclusion was based on historical 0.89–1.30; p = 0.46) [9]. However, these studies
data (October 1, 1983, to July 1, 2000). Recent are based on retrospective observational studies.
studies reported contrary findings, suggesting Selection bias and subsequent oncologic effec-
that both LDPS and LSPDP were associated with tiveness still remain to be resolved. Prospective,
similar perioperative complications and could be randomized controlled studies are necessary.
performed safely [43]. OPSI in patients with DPS However, well-selected patients and experienced
[44] is thought to be necessary, but POSI, in fact, surgeons should be involved to ensure patients’
is very rare in patients with elective PDS for non-­ safety [10]. Large-scale, multicenter studies
hematologic pathologic conditions, and preoper- investigating the long-term survival and onco-
ative vaccination is thought to be adequate for logic efficacy of pancreatic resection in pancre-
preventing critical long-term complications. The atic cancer have been reported [48–50].
potential role of spleen in adult patients requires
further investigation.
43.7.3 Role of Robotic Surgical
System in Laparoscopic Distal
43.7.2 Application in Left-Sided Pancreatectomy
Pancreatic Cancer
Theoretically, the robotic surgical system was
The theoretical advantages of LDP over open DP introduced for effective and safe minimally inva-
for left-sided pancreatic cancer include the sive surgery by addressing the limitations of the
following: conventional laparoscopic surgery, such as two-­
dimensional surgical field of view, attenuated touch
• Reduced inflammatory response during the sensation, limitation of intra-abdominal move-
recovery phase following surgical interven- ment, increased hand tremor, and fulcrum effect.
tion to prevent the progression of potential Accordingly, SpDP is considered to be the
residual cancer cells because the cytokines best indication for robotic surgery. In particular,
290 C. M. Kang

laparoscopic SVC-SpDP requires highly sophis- Korean multicenter study [61] supported the tech-
ticated manipulation to effectively and safely nical feasibility and safety of this new technique.
control the capillaries distributed between spleen Especially, Han and Kang [62] compared laparo-
vessels and the pancreas, which is mostly com- scopic and robotic approaches reduced port distal
pensated by the robotic surgical system. In addi- pancreatectomy. It was found that both techniques
tion, during SVS-SpDP, the robot may facilitate are technically feasible and safe. However, the
the safe excision of splenic vessels via effective robotic approach is superior to laparoscopic
dissection of the pancreas near the spleen hilum. approach in terms of operation time, blood loss,
Indeed, the authors reported that, in spite of severe complications, and hospital stay, suggest-
longer operation time compared to laparoscopic ing the need for further investigation.
surgery, the success rate of spleen preservation in
patients using robots was statistically significant
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 Laparoscopic Central
Pancreatectomy 44
Yoo-Seok Yoon

Abstract Keywords

Central pancreatectomy was introduced as a Central pancreatectomy · Laparoscopy

surgical procedure to replace distal pancre-
atectomy or pancreaticoduodenectomy in
patients with lesions around the pancreatic
44.1 Operative Procedure
neck. This procedure was first performed by
Dagradi and Serio in 1984 and widely imple-
44.1.1 Patient Position and Trocar
mented since Warshaw published a case series
Placement
involving 12 patients. The procedure is supe-
rior to other pancreatic resections in that it can
Under general anesthesia, the patient is placed in
preserve pancreatic exocrine and endocrine
the lithotomy position and in the reverse
functions by conserving pancreatic paren-
Trendelenburg position. The surgeon stands on
chyma. It can also preserve the upper gastroin-
the right side of the patient, whereas the assistant
testinal tract, bile ducts, and spleen. The main
stands left of the patient, and the scopist is posi-
indications for this procedure are benign or
tioned between the patient’s legs. After creation
low-malignant tumors located in the neck or
of CO2 pneumoperitoneum via a 12-mm infraum-
proximal body of the pancreas. The resection
bilical port, four additional trocars (two 12 mm
extends from the left of the gastroduodenal
each and two 5 mm each) are placed on both
artery to approximately 6 cm or more of the
sides of the upper abdomen in a curvilinear shape
distal pancreas after resection.
around the umbilicus trocar (Fig. 44.1). Two tro-
cars in the right upper abdomen are used as the
operator’s working ports and two trocars in the
upper left abdomen as ports for the assistant. A
Supplementary Information The online version con- scope with a 30° angle or a flexible scope can be
tains supplementary material available at https://doi. used to clearly visualize the superior area of the
org/10.1007/978-­981-­16-­1996-­0_44. pancreas.

Y.-S. Yoon (*)

Departments of Surgery, Seoul National University
Bundang Hospital, Seoul National University College
of Medicine, Seongnam, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 295

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_44
296 Y.-S. Yoon

Fig. 44.2 Full gastric mobilization from the anterior side

Fig. 44.1 Location of trocars of the pancreas

44.1.2 Approach to the Pancreas damaged pancreatic parenchyma. Small branches

of the SMV encountered during dissection are
The gastrocolic ligament is first divided at the controlled with energy devices. Once the SMV is
midline area and widely dissected toward the exposed, the posterior surface of the pancreas is
duodenum and spleen to expose the pancreas. dissected from the SMV toward the PV
The gastrocolic ligament is divided close to the (Fig. 44.3). As there are no branches on the ante-
gastroepiploic vessels so that the bulky omentum rior side of the SMV-PV, a retropancreatic tunnel
on the side of the stomach does not block the sur- is easily created via blunt dissection using a suc-
gical field. After the posterior side of the stomach tion tip.
is fully mobilized from the anterior side of the Thereafter, the superior border of the pancreas
pancreas (Fig. 44.2), the gastric antrum is sutured is dissected to expose the common hepatic artery
to the abdominal wall. This procedure can obvi- (CHA) with downward traction of the pancreas
ate the need for a trocar to maintain the surgical aided by the assistant. The pancreas is further dis-
field. If necessary, a laparoscopic ultrasound is sected from the CHA to expose the PV (Fig. 44.4).
performed to determine the location and extent of Care is taken to avoid injury to the coronary vein
the tumor. draining into the PV or splenic vein. When the
PV is fully dissected from the superior border of
the pancreas, a tape is passed around the pancre-
44.1.3 Dissection of the Pancreas atic neck through a window between the pancreas
and Exposure of the Superior and SMV-PV.
Mesenteric Vein (SMV)
and the Portal Vein (PV)
44.1.4 Proximal and Distal Pancreatic
The inferior pancreatic border is dissected until Division
the SMV is exposed after elevating the pancreatic
neck using the grasper. In this procedure, grasp- With traction of the tape, the proximal pancreas
ing the soft tissues around the pancreas rather is divided using an endoscopic linear stapler
than the pancreas itself reduces bleeding due to (Fig. 44.5). The type of cartridge is selected
44 Laparoscopic Central Pancreatectomy 297

Fig. 44.3 Dissection of the pancreatic surface from the Fig. 44.5 Division of the proximal pancreas using an
SMV toward the PV endoscopic linear stapler

Fig. 44.4 Dissection of the superior border of the pan-

creas to expose the PV. CHA common hepatic artery, LGA
left gastric artery, PV, portal vein

depending on the pancreatic thickness and tex-

ture. Thereafter, the pancreas is dissected from Fig. 44.6 Pancreatic dissection from the splenic vessels
toward the spleen: small branches of the splenic vessels
the splenic vessels toward the spleen. Small
are divided using endoclips. SV splenic vein
branches of the splenic vessels encountered dur-
ing dissection are divided using endoclips or
energy devices (Fig. 44.6). The distal pancreas is 44.1.5 Pancreatic Anastomosis
divided with an ultrasonic shear after mobilizing
the pancreas from the splenic vessels approxi- The proximal jejunum is transected approxi-
mately 2 cm away from the expected distal mar- mately 20 cm distal to the ligament of Treitz
gin (Fig. 44.7). Parenchymal transection is with an endoscopic linear stapler. The tran-
performed with ultrasonic shears at a peripheral sected proximal jejunum is brought up to the
site and scissors in the presumed area of the pan- remnant ­pancreas via an opening in the meso-
creatic duct to obtain a clear duct margin. colon. Pancreatic reconstruction is performed
298 Y.-S. Yoon

Fig. 44.7 Division of the distal pancreas using an ultra- Fig. 44.8 Pancreaticojejunostomy: outer-layer anasto-
sonic shear mosis between the pancreatic parenchyma and the sero-
muscular layer of the jejunum using a continuous running
suture
by the operator standing between both legs of
the patient and the camera inserted through the
right lower 12 mm trocar. A two-layer duct-to-
mucosa pancreaticojejunostomy is performed
in an end-to-side fashion (Figs. 44.8 and 44.9).
Continuous running 4–0 Prolene sutures are
used for outer-layer anastomosis between the
pancreatic parenchyma and the seromuscular
layer of the jejunum. Five to eight polydioxa-
none (PDS) 5–0 sutures are used for duct-to-
mucosa anastomosis depending on the size of
the pancreatic duct. After completion of the PJ,
a polyglycolic acid mesh is placed circumferen-
tially around the anastomosis, and fibrin glue is
applied. Thereafter, a side-to-side jejunojeju-
nostomy is performed using an endoscopic lin-
ear stapler, approximately 40 cm distal to the
pancreaticojejunostomy. The enterotomy is
closed using continuous 4–0 V-loc sutures Fig. 44.9 Pancreaticojejunostomy: duct-to-mucosa anas-
tomosis using interrupted sutures
(Fig. 44.10).
44 Laparoscopic Central Pancreatectomy 299

44.1.6 Drain Placement

Two Jackson-Pratt drains are placed near the pan-

creatic stump and pancreaticojejunostomy. The
surgical specimen is retrieved in a vinyl bag and
extracted through a small incision by extending a
port-site incision.

Fig. 44.10 Side-to-side jejunojejunostomy: closure of

the enterotomy using a continuous running suture
 Transduodenal Ampullectomy
of Ampullary Adenoma 45
Jinseok Heo and Wooil Kwon

Abstract 45.1 Introduction

Transduodenal ampullectomy remains a valid
Surgical resection is the mainstay of treatment
surgical procedure for ampullary adenoma,
for tumors of ampulla of Vater (AoV). It is need-
despite the emergence of endoscopic papil-
less to say that radical resection such as pancre-
lectomy. It is a relatively simple procedure;
aticoduodenectomy is required for AoV cancer.
however, there are critical issues that are asso-
Ampullary adenomas, although benign, still
ciated with serious outcomes, if overlooked.
require resection as they are known to be associ-
Therefore, hepatobiliary and pancreatic sur-
ated with concomitant adenocarcinoma in
geons should be familiar with the procedures.
25–60% of cases with potential risk of malignant
The procedures of transduodenal ampullec-
transformation [1, 2]. For these benign premalig-
tomy are briefly discussed here.
nant lesions, pancreatoduodenectomy appears
superfluous given the high rate and severity of
Keywords
complications and its adverse effects on the
Transduodenal ampullectomy · Ampulla of patient’s quality of life. In this regard, transduo-
Vater · Adenoma · Local excision · denal ampullectomy is more adequate for ampul-
Papillectomy lary adenoma considering the shorter operation
duration, shorter hospital stay, and lower morbid-
ity and mortality rate [3].
Supplementary Information The online version con- Endoscopic papillectomy is another alterna-
tains supplementary material available at https://doi. tive. However, it cannot be performed on some
org/10.1007/978-­981-­16-­1996-­0_45.
lesions with certain morphology and has limited
extent of resection [4]. Therefore, transduodenal
J. Heo (*) ampullectomy has a role in the treatment of
Department of Surgery, Samsung Medical Center, tumors of AoV.
Sungkyunkwan University School of Medicine,
Seoul, Korea
W. Kwon
Department of Surgery, Samsung Medical Center,
Sungkyunkwan University School of Medicine,
Seoul, Korea
Department of Surgery, Seoul National University
Hospital, Seoul, Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 301

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_45
302 J. Heo and W. Kwon

45.2 Indications quate field even when the operation is converted

and Contraindications to pancreatoduodenectomy. An upper midline
from the xyphoid process to supraumbilicus is
Transduodenal ampullectomy is indicated for vil- adequate but may be extended beneath the umbi-
lous adenoma, tubulovillous adenoma, adenoma licus. After laparotomy, intraperitoneal space,
with high-grade dysplasia, and carcinoma in situ including pelvic cavity, peritoneum, mesentery,
of AoV [5]. and liver, should be carefully examined and pal-
By contrast, the feasibility of transduodenal pated for unexpected findings such as seeding.
ampullectomy in adenocarcinoma is disputed due
to the risk of recurrence and regional lymph node
metastasis [6]. Those who advocate transduode- 45.4.2 Kocher Maneuver
nal ampullectomy in adenocarcinoma argue that
it may be used for well-differentiated, polypoid, Kocher maneuver should be performed mostly and
T1 tumors of grade 1–2, without lymphatic preferably to the left of inferior vena cava. Caudally,
spread, and measuring less than 3 cm [7, 8]. duodenum should be completely dissected from
However, it is generally not recommended due to the mesocolon to fully expose the third portion of
the high risk of recurrence [6, 9, 10]. However, duodenum. Generous dissection and mobilization
transduodenal ampullectomy may be reserved for of the duodenum facilitate the incision and closure
cancer patients who are contraindicated for radi- of duodenum and the approach to AoV.
cal surgery with either curative or palliative
purpose.
45.4.3 Incision of the Duodenum

45.3 Preoperative Evaluation The location of AoV can be confirmed by palpa-

tion if the tumor is large or by palpating the endo-
Endoscopic retrograde cholangiopancreatogra- scopic retrograde biliary drainage tube if it was
phy (ERCP) plays an important role in diagnosis placed preoperatively. In such case, incision can
and treatment [11]. The lesion can be directly be made over the palpated location. If the AoV
visualized with a side-viewing endoscope. Loss cannot be confirmed, an incision in the lower
of symmetry, mucosal erosion or ulceration, and third of the second portion of duodenum should
hard texture on probing imply adenocarcinoma provide good exposure of the AoV. A longitudi-
than adenoma. Notably, histopathological diag- nal incision of 3–4 cm is made with electrocau-
nosis can be established through biopsy using tery to expose the duodenal lumen and the AoV.
ERCP. Placing traction sutures along both sides of the
Endoscopic ultrasonography facilitates diag- incision and at each end of the incision may result
nosis and is particularly useful in evaluating the in better field (Fig. 45.1).
extent of pancreatic or bile duct involvement
[12–14].
45.4.4 Excision of the AoV

45.4 Surgical Procedures The line of excision around the AoV is determined
to ensure sufficient safety margin. Regarding the
45.4.1 Incision cephalic direction of the AoV as 12 o'clock, trac-
tion sutures are made inside and outside of the
Under general anesthesia, the patient is placed in excision line at 3 and 9 o'clock positions. Applying
supine position. Midline incision is preferred traction on these sutures generates tension on the
over right subcostal incision as it provides ade- line of excision. Using an electrosurgical needle
45 Transduodenal Ampullectomy of Ampullary Adenoma 303

Fig. 45.1 Ampulla of Vater can be easily exposed after

incising the lower third of the second portion of duode-
num. Four traction sutures are applied to the incision on
both sides and each end
Fig. 45.2 With adequate excision of the ampulla of Vater,
the openings of the bile duct (BD) and the pancreatic duct
(PD) can be visualized separately
tip, the AoV is excised circumferentially. Using a
cutting mode rather than coagulation mode causes
less damage and disfiguration of the margin, which 45.4.5 Ductoplasty of the Bile
will facilitate evaluation of the margin status and and Pancreatic Ducts
reconstruction. However, hemostasis may be less
efficient and bleeding points should be focally Upon complete excision, the bile and pancreatic
cauterized using the coagulation mode. In addition ducts should be formed into a common duct by
to the traction sutures, the operator and the assis- suturing the adjacent walls using 5-0 polydioxa-
tant should apply counter-traction with fine for- none (PDS) sutures (Fig. 45.3). They can be
ceps to create tension over the excision line along sutured either continuously or interrupted accord-
with the resection. ing to the preference of the operator.
In terms of the depth of excision, the operator
should ensure that the AoV is completely excised
to include the common channel of bile and pan- 45.4.6 Implantation of Common
creatic ducts. If the AoV is excised to adequate Duct into Duodenum
depth, the separate openings of the common bile
duct and the pancreatic duct should be visible at The common duct should be implanted into the
the deep margin after removing the specimen mucosa of the duodenum. The common duct is
(Fig. 45.2). The pancreatic duct is caudal to the sutured in interrupted manner to the duodenal
common bile duct. Frozen section should be sent mucosa around its circumference at regular inter-
to evaluate the margin status. Lateral margins vals using 5-0 PDS (Fig. 45.4). Authors find 8–16
should also be checked from the mucosae at 3, 6, sutures to be sufficient.
9, 12 o'clock positions or any other parts deemed Before closing the duodenum, the retroperito-
necessary. The bile duct and pancreatic duct mar- neal side of duodenum should be carefully exam-
gins should also be sent for frozen section. ined for any wall defects, as duodenal wall may
Additional resection should be performed if mar- be perforated easily if the AoV is resected too
gin is not clear. Conversion to pancreatoduode- wide or deep. If a wall defect is identified, pri-
nectomy should not be delayed if the margin mary repair should be done.
cannot be secured or malignancy is confirmed.
304 J. Heo and W. Kwon

Fig. 45.3 Common channel is formed by suturing the

bile duct (BD) and the pancreatic duct (PD) using 5–0
polydioxanone
Fig. 45.5 Duodenal opening can be closed either longi-
tudinally or transversely. The transversely closed duode-
num is illustrated, but the incidence of stricture is low
even after longitudinal closure

discretion. The incision may be closed transversely

when there is a risk of possible stricture. However,
strictures are rare even after longitudinal closure.

45.4.8 Drain Insertion

and Abdominal Wall Closure

The duodenum is replaced to its original position

Fig. 45.4 Common channel of the bile duct (BD) and the
pancreatic duct (PD) is implanted into the duodenum. The and the peritoneal cavity is washed with saline.
patency of both openings is well preserved Authors recommend inserting surgical drain to
monitor hemorrhage or duodenal leakage. Closed
negative pressure drainage is preferred such as
45.4.7 Closure of Duodenostomy Jackson–Pratt drain. The surgical drain should be
placed near the duodenal repair site. However,
Duodenostomy should be closed in 2 layers after caution should be taken not to leave the drain in
evaluating the patency of the bile and pancreatic direct contact with the repair site as this may have
ducts with probes (Fig. 45.5). Both longitudinal adverse effect on wound healing.
and transverse closure can be done at the operator’s Abdominal wall is closed in a usual manner.
45 Transduodenal Ampullectomy of Ampullary Adenoma 305

3. de Castro SM, van Heek NT, Kuhlmann KF, Busch

Tips: Essential Points OR, Offerhaus GJ, van Gulik TM, et al. Surgical man-
agement of neoplasms of the ampulla of Vater: local
1. A generous Kocher maneuver should be resection or pancreatoduodenectomy and prognostic
performed for better mobilization and factors for survival. Surgery. 2004;136(5):994–1002.
exposure of the duodenum and the AoV. 4. van der Wiel SE, Poley JW, Koch AD, Bruno
2. The AoV should be excised to adequate MJ. Endoscopic resection of advanced ampullary ade-
nomas: a single-center 14-year retrospective cohort
depth, and the bile and pancreatic duct study. Surg Endosc. 2019;33(4):1180–8.
openings should be separately identified 5. Paramythiotis D, Kleeff J, Wirtz M, Friess H, Buchler
after resection. MW. Still any role for transduodenal local excision
3. The patency of both ducts should be in tumors of the papilla of Vater? J Hepatobiliary
Pancreat Surg. 2004;11(4):239–44.
determined after implanting the com- 6. Winter JM, Cameron JL, Olino K, Herman JM, de
mon duct of bile and pancreatic ducts. Jong MC, Hruban RH, et al. Clinicopathologic analy-
4. Retroperitoneal duodenum should be sis of ampullary neoplasms in 450 patients: implica-
examined for any wall defects inflicted tions for surgical strategy and long-term prognosis. J
Gastrointest Surg. 2010;14(2):379–87.
during the excision. 7. Beger HG, Treitschke F, Gansauge F, Harada N,
Hiki N, Mattfeldt T. Tumor of the ampulla of
Vater: experience with local or radical resection
in 171 consecutively treated patients. Arch Surg.
1999;134(5):526–32.
45.5 Conclusion 8. Klein P, Reingruber B, Kastl S, Dworak O,
Hohenberger W. Is local excision of pT1-­
Transduodenal ampullectomy is an essential surgi- ampullary carcinomas justified? Eur J Surg Oncol.
1996;22(4):366–71.
cal intervention for ampullary adenoma. In addi- 9. Sperti C, Pasquali C, Piccoli A, Sernagiotto
tion, it may be offered to AoV cancer patients C, Pedrazzoli S. Radical resection for ampul-
who are contraindicated for radical operation. lary carcinoma: long-term results. Br J Surg.
Endoscopic papillectomy may have partially 1994;81(5):668–71.
10. Asbun HJ, Rossi RL, Munson JL. Local resection for
replaced transduodenal ampullectomy. However, ampullary tumors. Is there a place for it? Arch Surg.
there are adenomas that are beyond the capabil- 1993;128(5):515–20.
ity of endoscopic papillectomy. Therefore, trans- 11. El H II, Cote GA. Endoscopic diagnosis and manage-
duodenal ampullectomy remains an important ment of ampullary lesions. Gastrointest Endosc Clin
N Am. 2013;23(1):95–109.
component of the treatment for AoV tumors. 12. Rattner DW, Fernandez-del Castillo C, Brugge
Hepatobiliary and pancreatic surgeons should WR, Warshaw AL. Defining the criteria for local
have a thorough knowledge of procedures involv- resection of ampullary neoplasms. Arch Surg.
ing transduodenal ampullectomy. 1996;131(4):366–71.
13. Mukai H, Nakajima M, Yasuda K, Mizuno S, Kawai
K. Evaluation of endoscopic ultrasonography in the
pre-operative staging of carcinoma of the ampulla of
References Vater and common bile duct. Gastrointest Endosc.
1992;38(6):676–83.
1. Posner S, Colletti L, Knol J, Mulholland M, Eckhauser 14. Rosch T, Braig C, Gain T, Feuerbach S, Siewert
F. Safety and long-term efficacy of transduodenal JR, Schusdziarra V, et al. Staging of pancreatic and
excision for tumors of the ampulla of Vater. Surgery. ampullary carcinoma by endoscopic ultrasonography.
2000;128(4):694–701. Comparison with conventional sonography, computed
2. Fischer HP, Zhou H. Pathogenesis of carcinoma of tomography, and angiography. Gastroenterology.
the papilla of Vater. J Hepatobiliary Pancreat Surg. 1992;102(1):188–99.
2004;11(5):301–9.
 Essential Tips for Pancreatic
and Duodenal Surgery: Vessel 46
Resection

Song Cheol Kim and Dae Wook Hwang

Abstract 46.1 Combined Venous Resection

A combined vascular resection is indicated for
46.1.1 End-to-End Anastomosis
a few patients with periampullary cancers and
cancers of pancreatic body and tail. In this
En bloc resection is indicated for the tumors in
chapter, we discuss the basic strategy for ves-
direct contact with the portal vein (PV) or supe-
sel resection and anastomosis according to the
rior mesenteric vein (SMV) in preoperative imag-
type and location of vascular invasion.
ing studies. Preferentially, segmental, cylindrical
PV/SMV resection with end-to-end anastomos is
Keywords
can be considered, and even the length of the
Periampullary cancer · Pancreatic cancer · resected vein can range from 3 to 5 cm [1]. It
Vascular invasion · Venous resection · Arterial should be noted that a large enough dissection
resection · Portal vein · Superior mesenteric involving the proximal/distal portion of the
vein · Superior mesenteric artery · Celiac axis resected PV or SMV is required to reduce the
· Hepatic artery tension load on the anastomosis. If resection of
the confluence between the PV, SMV, and the
splenic vein is needed, anastomosis of the splenic
vein is recommended to prevent the potential risk
of developing left-sided portal hypertension.
If the cross-section reveals infiltration of less
than one-third of the PV or SMV, a primary repair
after wedge resection or patch insertion of autog-
enous/artificial vessels is indicated.
End-to-end anastomosis is not significantly
Supplementary Information The online version con-
tains supplementary material available at https://doi. different from general vascular anastomosis,
org/10.1007/978-­981-­16-­1996-­0_46. which requires an approximately 5-0 or 6-0-sized
nonabsorbable monofilament suture, such as
Prolene or Surgipro reflecting growth factors
S. C. Kim (*) · D. W. Hwang
Division of Hepatobiliary and Pancreatic Surgery, (Fig. 46.1) [2, 3].
Department of Surgery, Asan Medical Center,
University of Ulsan College of Medicine,
Seoul, South Korea
e-mail: [email protected]

© Springer Nature Singapore Pte Ltd. 2023 307

H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_46
308 S. C. Kim and D. W. Hwang

a b

Fig. 46.1 (a) End-to-end anastomosis after main portal vein resection. (b) End-to-end anastomosis after PV-SMV-SV
confluence without SV reconstruction

46.1.2 Interposition Grafting 46.1.2.3 Xenogenic Graft, Bovine

Pericardial Patch
In case of tumor infiltration longer than 5 cm into Similar to Gore-Tex®, the xenograft (bovine peri-
the superior mesenteric or the portal vein, inter- cardial patch) has excellent biocompatibility
position grafting can be considered. Although without allergic reaction and can be used imme-
there is no significant difference in the method of diately. Its size and shape can be decided by the
anastomosis, it is important to examine the char- operator. In terms of material stiffness, it is closer
acteristics of each graft for anastomosis. While to autogenous vessels than to Gore-Tex®, thus
tension at the anastomotic site should be moni- reducing the risk of subsequent strictures. It is
tored, the graft should be 60–70% in proportion also hemodynamically similar to autogenous ves-
to the actual length of the resection, in order to sels. As its stiffness is between that of autogenous
avoid kinking or acute angulation around the vessels and Gore-Tex®, it is difficult to decide the
anastomotic site. growth factors to use after the suture (the author
uses 0.3–0.5). Also, the grafts can cause infection
46.1.2.1 Autogenous Vessels (Fig. 46.2).
A well-known method utilizes the internal jugular
vein, the left renal vein, and the saphenous vein. 46.1.2.4 Artificial Graft:
The actual length is significantly shortened after Polytetrafluoroethylene
resection of the veins in many cases, and it should (PTFE, Gore-Tex®) Grafts
be fully considered before making a decision. Gore-Tex® does not cause allergic reactions and
This is the best graft due to its biocompatibility has an excellent biocompatibility and a low rate
and low rates of vascular occlusion associated of thrombogenesis. However, artificial grafts are
with thrombosis or anastomotic strictures. not histocompatible; they also increase the risk of
infection and weak encapsulation. Its size and
46.1.2.2 Cadaveric Vessels shape can be decided by the operator and is mini-
Cadaveric vessels are similar to autogenous ves- mally reduced in length by suture. A constant
sels. However, they cannot be used unless they shape can be maintained. Thus, this method can
are designed for grafting in liver/kidney/pancreas be used when the autogenous vessels or other
transplantation. grafts are contraindicated [4].
46 Essential Tips for Pancreatic and Duodenal Surgery: Vessel Resection 309

Fig. 46.2 Interposition grafting using bovine pericardial Fig. 46.3 Combined hepatic arterial and portal venous
patch, after long segment venous resection resection with end-to-end anastomosis

46.2 Combined Arterial Resection 46.2.2 Distal Pancreatectomy

with Celiac Axis Resection
46.2.1 Proper Hepatic/Right Hepatic (DP-CAR, Appleby Operation)
Arterial Resection
A combined celiac axis resection can be consid-
Resection of the common hepatic artery or the ered if tumors infiltrate into the celiac axis or the
proper hepatic artery is sometimes required proximal segment of the common hepatic artery,
because of tumor infiltration, in which adequate left gastric artery, or splenic artery of the celiac
length of the gastroduodenal artery stump should axis. The prerequisites for combined celiac axis
be secured and used to ensure the hepatic arterial resection to ensure negative surgical margins
flow. If it is not possible to secure the gastroduo- from an oncologic perspective include the fol-
denal artery stump, end-to-end anastomosis with lowing: at least 5-mm-long segment without
or without autogenous vessels/artificial grafts, as tumor infiltration at the proximal segment of the
described above, can be considered (Fig. 46.3). celiac axis from the aorta; absence of tumor infil-
The right hepatic artery and common hepatic tration into the superior mesenteric artery; and
artery often show variations originating from the patent gastroduodenal artery. In most cases in
superior mesenteric artery. Arterial resection is which surgery is considered, it is difficult to iden-
unavoidable for radical resection during pancreati- tify the proximal segment of the celiac axis using
coduodenectomy when these arteries course into the anterior approach. Thus, it is helpful to con-
the pancreatic head. A combined resection can be duct resection after the identification of the prox-
performed even when tumors infiltrate into the imal segment of the celiac axis from the aorta via
accessory right hepatic artery. The replaced right Kocher’s maneuver. Further, any infiltration into
hepatic artery also rarely causes ischemic chal- the proximal portion of the superior mesenteric
lenges in the liver because the hepatic collateral cir- artery (SMA) should be evaluated using the SMA
culation is preserved or collateral circulation occurs approach, followed by pancreatic parenchymal
later via the hepatic capsular arteries. In case of resection along the left border of the gastroduo-
tumor infiltration into the replaced common hepatic denal artery, and en bloc resection around the
artery, however, an anastomosis is required to secure celiac axis. If combined resection of the portal
hepatic arterial flow after the resection, for which vein is required at the same time, the distal/proxi-
end-to-end anastomosis with or without autogenous mal portion of the portal vein should be dissected
vessels/artificial grafts can be considered [5]. clearly before resection of pancreatic paren-
310 S. C. Kim and D. W. Hwang

chyma, which facilitates resection of the portal References

vein and anastomosis.
1. Kim SC. Surgical management of pancreatic cancer.
Korean J Gastroenterol. 2008;51(2):89–100.
2. Yoshitomi H, Kato A, Shimizu H, Ohtsuka M,
46.2.3 Resection of Superior Furukawa K, Takayashiki T, et al. Tips and tricks
Mesenteric Artery of surgical technique for pancreatic cancer: portal
vein resection and reconstruction (with videos). J
Hepatobiliary Pancreat Sci. 2014;21(9):E69–74.
SMA is one of main abdominal arteries and 3. Hwang JW, Kim SC, Song KB, Yoon JH, Nam JS,
together with hepatic artery and celiac axis, con- Lee JH, et al. Significance of radiologic location and
sidered in marginal contraindication to resection. extent of portal venous involvement on prognosis after
However, in some rare cases, the resection of resection for pancreatic adenocarcinoma. Pancreas.
2015;44(4):665–71.
SMA is considered curative. In most of those 4. Kamenskiy AV, Mactaggart JN, Pipinos GPK II,
cases, en bloc resection with primary end-to-end Dzenis YA. Hemodynamically motivated choice of
anastomosis can be performed with caution con- patch angioplasty for the performance of carotid end-
sidering the intraoperative and postoperative arterectomy. Ann Biomed Eng. 2013;41(2):263–78.
5. Michels NA. Newer anatomy of the liver and its vari-
ischemic changes of small bowel (Fig. 46.4). ant blood supply and collateral circulation. Am J Surg.
1966;112(3):337–47.

Fig. 46.4 Combined SMA and SMV resection with end-­

to-­end anastomosis
 Essential Tips for Reconstruction
After Pancreaticoduodenectomy 47
Sung-Sik Han, Dong Eun Park, Koo Jeong Kang,
and Young Kyoung You

Abstract internal or external stent. Also, there is contro-

versy regarding the usefulness of stent inser-
Pancreatico-enteric anastomosis is the most
tion. Herein, we introduce two most frequently
critical procedure in pancreaticoduodenec-
performed techniques of pancreatico-enteric
tomy, because post-operative pancreatic fis-
anastomosis and transhepatic external drain-
tula (POPF) sometimes causes severe
age technique of pancreatic juice after
morbidity and even mortality. Since pancreati-
anastomosis.
coduodenectomy was introduced in 1935,
countless techniques were conducted to
Keywords
reduce the POPF. However, until now, no stan-
dardized method was established. Any type of Pancreaticoduodenectomy · Pancreatico-­
anastomosis has advantages as well as disad- jejunostomy · Pancreatico-gastrostomy ·
vantages. Thus, which method to choose may Pancreatic stent · External drainage ·
vary depending on the operator’s preference Modified Blumgart pancreaticojejunostomy ·
and experience. Regarding stent insertion, Conventional pancreaticojejunostomy
there are various reports about the choice of

S.-S. Han (*) 47.1 Pancreaticojejunostomy

Center for Liver and Pancreatobiliary Cancer,
National Cancer Center, Goyang, South Korea
e-mail: [email protected] Anastomosis of the pancreatic stump with the
D. E. Park gastrointestinal tract is considered the most
Department of Surgery, Wonkwang University challenging feature of surgery, and is crucial
college of Medicine, Iksan, South Korea for postoperative healing. Technical failure at
e-mail: [email protected] this point causes postoperative pancreatic fis-
K. J. Kang tula (POPF), a potentially fatal complication.
Division of Hepatobiliary and Pancreatic Surgery, Pancreaticojejunostomy and pancreaticogastros-
Department of Surgery, Keimyung University
Dongsan Hospital, Daegu, South Korea tomy are the most frequently performed proce-
e-mail: [email protected] dures for anastomosis between the pancreas and
Y. K. You the gastrointestinal tract. Even though more than
Division of Hepatobiliary Pancreas Surgery and Liver 80 years have passed since the first pancreatico-
Transplantation, Department of Surgery, Seoul St. duodenectomy was introduced, no safe, effective
Mary’s Hospital, College of Medicine, The Catholic and universally accepted technique is available to
University of Korea, Seoul, South Korea
e-mail: [email protected]
© Springer Nature Singapore Pte Ltd. 2023 311
H. C. Yu (ed.), Hepato-Biliary-Pancreatic Surgery and Liver Transplantation,
https://doi.org/10.1007/978-981-16-1996-0_47
312 S.-S. Han et al.

minimize pancreatic leakage. The anastomosis

appears to depend on the surgeon’s preference
and the characteristics of the pancreas. Herein,
I present the modified Blumgart pancreaticojeju-
nostomy technique and conventional 2-layer pan-
creaticojejunostomy, which I use most frequently.

47.1.1 Modified Blumgart Duct-to-­

Mucosa Technique

Blumgart pancreatico-jejunostomy entails the Fig. 47.1 Three U-sutures were applied and hold untied
use of transpancreatic and jejunal seromuscular
U-sutures (outer layer) to approximate the pan-
creatic stump and the jejunum combined with
duct-to-mucosa (inner layer) anastomosis.
Approximately 20 mm of the pancreatic
stump is freed from the splenic vein and sur-
rounding tissues following transection of the
pancreatic neck. The jejunal limb is lifted up
through the transverse mesocolon next to the
right side of the second portion of the duode-
num. The ante-­ mesenteric side of the jejunal
limb is placed next to the pancreatic stump. A
3-0 prolene® is used for the transpancreatic and
Fig. 47.2 PDS 5-0 interrupted sutures were applied for
jejunalseromuscular suture. The needle should duct-to-mucosa anastomosis
be straightened before suture in order to easily
penetrate the whole thickness of the pancreas.
The needle is passed from the anterior to the pos-
terior surface of the pancreas, about 10 mm from
its cut edge. It is then passed through the sero-
muscular layer of the jejunum, parallel to its
long axis, and again from the posterior to the
anterior surface of the pancreatic parenchyma,
about 5 mm away from the initial entry. I place
only 3 U-sutures in order to enhance the perfu-
sion of the pancreatic stump and each suture is
placed 2–3 mm next to the previous one. These Fig. 47.3 Anterior sero-muscular suture of the jejunum,
sutures are left untied until the duct-to-mucosa parallel to its long axis
anastomosis is performed (Fig. 47.1). After cre-
ating a tiny hole on the jejunum, the PDS® 5-0 is while doing the U-suture and to ensure the con-
used for the duct-to-mucosa anastomosis with tinuity of the anastomosis postoperatively. After
interrupted sutures. The number of PDS® sutures the duct-to-mucosa sutures are tied, the straight-
depends on the pancreatic duct size: usually four ened needles of these untied U-sutures are passed
sutures for non-dilated duct and six sutures for again through the seromuscular layer of the jeju-
dilated duct (Fig. 47.2). I always insert a plastic num, parallel to its long axis, (Fig. 47.3) and tied
stent inside the duct to avoid ductal collapse on the anterior surface of the pancreas.
47 Essential Tips for Reconstruction After Pancreaticoduodenectomy 313

47.1.2 Conventional 2-Layer Duct-to-­ the duct and the intestine are sutured and tied
Mucosa Technique after stent insertion. Finally, the anastomosis
between the anterior layer of the pancreatic
The conventional 2-layer duct-to-mucosa anasto- parenchyma and the intestinal wall is performed
mosis is still widely performed in many institu- using the same 4-0 prolene® continuous suture,
tions. It entails suturing inner layer of which was used for the posterior outer layer
duct-to-mucosa and outer layer of continuous (Fig. 47.6). Two closed-suction drains are placed
suturing of pancreatic parenchyma with the jeju- anterior and posterior to the anastomotic site.
nal seromuscular layer.
A 4-0 prolene® continuous suture is applied
from the posterior part of the pancreatic capsule
(parallel to the axis of the pancreas, 1 cm from
the cut edge) and through the seromuscular layer
of the intestine (Fig. 47.4). A smaller intestinal
opening than the pancreatic duct is created elec-
trosurgically on the side opposite to the pancre-
atic duct. The intestinal mucosa is pulled out to
perform a precise suture of the mucosa with the
duct. The intestinal opening should be smaller
than the pancreatic duct opening because the
mucosal opening is prone to enlarge during the
anastomosis. The 5-0 PDS® interrupted sutures
are applied between the pancreatic duct and the
whole layer of the intestinal wall. Sutures of the
posterior wall of the duct and the intestine are
tied and cut. Pancreatic stent is inserted if needed
to secure the anastomosis (Fig. 47.5). I usually
Fig. 47.5 Short pancreratic stent is inserted to secure the
use a pediatric feeding tube. The anterior wall of anastomosis

Fig. 47.4 Continuous suture is applied from the posterior

part of the pancreatic capsule Fig. 47.6 The anterior layer of the pancreatic paren-
chyma and the intestinal wall are sutured
314 S.-S. Han et al.

47.2 External Drainage 1. Interrrupted suture between the entire pancreas

of Pancreatic Duct and the seromuscular layer of the jejunum
First, flatten the needle of the absorbable
47.2.1 Transjejunal External suture (2-0, 3-0 Vicryl®) using forceps. After
Drainage of Pancreatic Duct penetrating the parenchyma of the pancreas
from the front to the back at a distance of
47.2.1.1 Background about 1 cm from the cut surface of the pan-
Although there are contrasting opinions about the creas, suture the seromuscular layer near the
usefulness of pancreatic stent insertion during mesenteric border of the jejunum. Without
pancreatic anastomosis, a recent prospective ran- ligating the suture, hang it on the forceps with
domized multicenter study reported that the inci- the needle attached. The spacing is approxi-
dence of the pancreatic fistula was significantly mately 0.75 cm. Four to six interrupted
reduced when a stent was used. A short stent is sutures are performed, and it should be noted
inserted into the pancreatic duct and drained that the main pancreatic ducts are not sutured
through the jejunal loop. It can be divided into the together; placing a thin probe in the pancre-
internal drainage method and the external drain- atic duct is one of the ways to prevent this
age method, in which it is pulled out of the pan- (Fig. 47.7).
creas for a long time through the jejunum or liver. 2. The duct-to-mucosa anastomosis and pancre-
The internal drainage method is easy to manage, atic stent insertion
but the stent remains at the site of the duct-to-jeju- For the duct-to-mucosa anastomosis, a
nal anastomosis and can cause atrophy of the small hole is made in the jejunum, corre-
residual pancreas. On the other hand, the external sponding to the pancreatic duct using an
drainage can increase the anastomosis stability electric cauterizer or scalpel. A stent must be
but the management of the tube is complicated. placed prior to the anastomosis. Depending
The choice of the drainage method may depend on the inner diameter of the pancreatic duct,
on the operator’s preference. A recent prospective a 3–8 Fr silastic tube can be used. The author
randomized study comparing the internal and mainly uses newborns’ feeding tubes. Insert
external drainage methods reported that the inci- a thin explorer through the pre-drilled hole
dence of pancreatic fistula after surgery did not and advance to the lower jejunum to more
differ according to the drainage method. than 10 cm. After the explorer comes out of
the jejunum which is 10 cm lower from the
47.2.1.2 Surgical Technique opening, it is tied with a prepared feeding
The order of stent insertion differs depending on tube. They are pulled out of the opening and
the methods of pancreatic anastomosis. In the the explorer is removed. Next, perform pos-
case of the dunking method, a stent is inserted and terior duct-to-mucosa anastomosis with
ligated to the pancreatic duct. In duct-to-mucosa approximately three to four interrupted
anastomosis, a stent is inserted after the anasto- sutures with absorbable sutures (5-0 PDS). A
mosis of the posterior layer of the pancreatic duct. previously prepared stent is placed in the
Here the authors will describe stent insertion pancreatic duct. When inserting it, be careful
mainly in duct-to-mucosa anastomosis. The not to exceed 2–3 cm; if it is inserted too
author mainly uses the so-called novel pancreati- deeply, it can cause postoperative pancreati-
cojejunostomy method as proposed by Grobmyer tis. After ligating and fixing the stent using
et al. The aim of this procedure is to prevent rup- the remaining sutures used for the rear
ture of the suture site by firmly fixing the pancreas suture, Approximately three or four stiches
to the jejunum by suturing the entire parenchyma are needed to perform an anterior duct-to-
of the remaining pancreas with the jejunum. mucosa anastomosis (Fig. 47.7).
47 Essential Tips for Reconstruction After Pancreaticoduodenectomy 315

Fig. 47.7 The interrrupted sutures of the whole thickness

Fig. 47.8 The anterior jejunal seromuscular sutures and
of pancreas and posterior jejunal seromuscular layer.
stent fixation. After completion of the duct-to-mucosa
First, a flattened needle is passed from the front to the
anastomosis, vicryl sutures are tied down and not to be
back at a distance of 1 cm from the edge of the transected
cut. Using the vicryl sutures, the anterior jejunal seromus-
pancreas. Then, after forming a seromuscular suture with
cular sutures are completed. The horizontal mattress
the jejunum in a horizontal mattress manner, the needle is
sutures can allow the jejunum to fold over the anterior sur-
again passed from the back to the front of the pancreas.
face of the pancreas. The jejunum site where the stent
During this process, a probe such as a feeding tube is
came out is fixed with a purse-string suture, and several
placed in the duct to prevent occlusion. After posterior
seromuscular stitches are made approximately 3–5 cm in
duct-to-mucosa anastomosis is performed using PDS 5-0,
length over it
the stent is fixed by simple suture in the middle thread.
Then proceed with anterior duct-to-mucosa anastomosis
an appropriate area on the right side of the
flank. Then, the serosal membrane of the jeju-
3. The final anterior row of the anastomosis and num and the parietal peritoneum from which
fixing a external stent. the drainage tube came out is sewn up using
After the duct-to-mucosa anastomosis is absorbent sutures.
completed, the remaining posterior sutrues
(3-0 Vicryl®) are ligated without pulling too 47.2.1.3 Post-Surgery Management
hard and cutting needles. After ligating all the The drainage is drained naturally using a bile
posterior sutures, perform an anterior sero- bag, etc. The amount of drainage per day varies
muscular suture of the jejunum using the from patient to patient, but in the case of the
remaining needle. After the horizontal mat- authors, approximately 100–200 mL of clear
tress like the posterior layer is sutured, the water-like pancreatic juice was drained per day.
needle tip is withdrawn toward the origin of There are cases where the color of the drainage
the pancreas, ligated and cut (Fig. 47.8). changes to that of the bile. These cases happen
Next, a procedure to fix the external drain- when, first, the stent in the pancreatic duct is nat-
age tube is done. Approximately 10 cm below urally removed and is placed in the jejunum, and
the pancreatic anastomosis site, the drain tube second, when the pancreatic jejunal anastomosis
exiting from the jejunum is fixed with a purse- is leaked. In this case, confirmation through an
string suture, and the drain tube is covered abdominal CT scan is recommended, and in some
with a seromuscular suture of approximately cases, 10 cc or less of a contrast medium (gastro-
3–5 cm like in gastrostomy. The drainage tube graphin) is spread using the drain tube. A fistulo-
exit from the body through a skin incision in gram may also be helpful.
316 S.-S. Han et al.

Major complications, and the removal time of drainage may result in leakage of the intestinal
the external drainage tube differ from operator to juice from the jejunal opening, whereas transhe-
operator, but in the case of the author, the removal patic drainage is technically challenging and
was performed approximately 2 weeks after the requires a device (Fig. 47.9a), but it is safer than
operation, considering the time when the tension the transjejunal route. A stylet with a hole at the
of the absorbable suture is reduced by half. end of the tip is inserted into the cut bile duct cut
and the hepatic surface, and mainly the left lateral
section (B2or B3) of the liver is selected. A per-
47.2.2 Transhepatic External cutaneous preput polyethylene catheter is pulled
Drainage of Pancreatic Duct after connecting it to the tip of the stylet. The cut
end of the common hepatic duct is pulled out and
The rate of postoperative pancreatic fistula inserted into the pancreatic duct through the jeju-
(POPF) in case of soft pancreas with a pancreatic num. The tube is fixed tightly with the pancreatic
duct measuring less than 3 mm in diameter is duct using a PDS 5-0 purse-string suture. The
higher in distal bile duct cancer compared with schematic diagram after completion of this pro-
pancreatic cancer involving a firm pancreatic cedure is shown in Fig. 47.7b. The tube is
parenchyma with a pancreatic duct size larger removed after confirming the absence of postop-
than 3 mm. The external diversion of the pancre- erative leakage for 2–3 weeks.
atic juice is very safe even in case of POPF The author’s algorithm for the transhepatic
because of limited intraperitoneal leakage of the external drainage or anastomosis without any
pancreatic juice (1). External drainage occurs via drainage (internal of external) is depicted in
transjejunal and transhepatic routes. Transjejunal Fig. 47.10.

a b

Fig. 47.9 A schematic diagram of pancreatico-­ and a polyethylene tube is inserted into the bile duct. (b)
jejunostomy and transhepatic external drainage of pancre- Completion of pancreaticojejunostomy and insertion of
atic juice. (a) A stainless steel stylet with a hole at the end transhepatic pancreatic tube and two J-P catheters
47 Essential Tips for Reconstruction After Pancreaticoduodenectomy 317

Consistency of the pancreatic parenchyma

and the duct diameter

Soft pancreas & Firm pancreas &

duct diameter<3mm duct diamter > 3mm

End to side pancreatico-jejunostomy Duct to mucosal anastosis

with external drainage without any drainage

Fig. 47.10 Algorithm of pancreatico-jejunostomy according to the consistency of the pancreatic parenchyma and
diameter of the duct

47.3 Pancreaticogastrostomy 47.3.2 Preparation of Stomach

Failure of pancreatic anastomosis is a major con- Tension at the pancreaticoenteric anastomosis is

cern associated with pancreaticoenteric anasto- one of the major risk factors underlying anasto-
mosis. A variety of anastomotic techniques have motic failure. Constrained sharp ventral bending
been used to secure the postoperative pancreatic over the pancreatic body to the gastric wall leads
anastomosis. However, pancreaticojejunostomy to continuous tension at the pancreaticogastric
is a significant risk factor, especially, in soft pan- anastomosis. Adequate length of pancreatic
creas. Therefore, pancreaticogastrostomy is the stump and gastric antral area is essential to avoid
only option to minimize the risk of failure in pan- tension at the pancreaticogastric anastomosis
creaticoenteric anastomosis. with organ configuration. Classical Whipple’s
operation involves gastric anastomosis for full
mobilization of gastric body and fundic area
47.3.1 Preparation of Pancreas ensuring short gastric vessel at the splenic
portion.
Adequate bleeding control of the remnant pan- Inadequate hemostasis at the gastric wall war-
creatic stump is essential prior to pancreaticoen- rants postoperative gastroscopy for the manage-
teric anastomosis. Suture ligation using 5-0 or ment of bleeding focus, which increases the risk
6-0 monofilament suture material rather than dia- of pancreaticogastric anastomotic failure.
thermic or energy device ensures clean resection
margin and minimal risk of postoperative
bleeding. 47.3.3 Pancreatic-Gastric
Pancreatic stump should be freed from the ret- Anastomosis
roperitoneal tissue at least 3 cm in length.
Adequate length of pancreatic stump enables safe Secure and tension-free anastomotic conditions
invagination into the anastomotic gastric lumen. are a prerequisite for surgical success. Based on
Pancreatic duct stent using a plastic tube is the elasticity of gastric wall, a relatively small
determined by the duct diameter and location of opening allows invagination of pancreatic stump
orifice. Pancreatic duct opening near periphery of at least 1 cm. Anterior wall longitudinal gas-
without stenting results in suture obstruction dur- trotomy facilitates pancreaticogastric anastomo-
ing anastomosis. sis. A full-thickness gastric interrupted suture can
318 S.-S. Han et al.

47.3.4 Pros and Cons

of Pancreaticogastrostomy

Diminished long-term endocrine function of

the pancreatic remnant is the most significant
concern associated with pancreaticogastros-
tomy. Nevertheless pancreaticogastric recon-
struction represents an appropriate option for
soft pancreas and individuals with unexpected
long-term cancer survival, to prevent anasto-
motic failure. Gastroscopy represents an effec-
tive tool to manage the postoperative pancreatic
stump.
Fig. 47.11 Pancreaticogastrostomy is performed with
anterior gastrotomy. A full-thickness gastric interrupted
sutures are anchored to pancreas with 5-0 PDS
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