Right Hemihepatectomy
Executive Summary
The following briefing document outlines the surgical protocols and clinical considerations for a right hemihepatectomy, as detailed by Christoph Tschuor and Pierre-Alain Clavien. The procedure is a complex seven-step operation requiring precise anatomical identification, vascular control, and physiological management.
Critical takeaways include:
Anatomical Vigilance: Surgeons must account for significant arterial variations, such as aberrant left hepatic arteries (found in 20–25% of patients) and aberrant right hepatic arteries (found in 10–15%).
Hemodynamic Management: Maintaining a low central venous pressure (CVP)—ideally below 3 mm Hg—is vital for reducing blood loss during parenchymal transsection.
Vascular Control: The procedure utilizes techniques such as the Pringle maneuver and specific ligation methods for the right portal vein and hepatic veins to ensure a controlled surgical field.
Post-Resection Stability: The reattachment of the falciform ligament is essential to prevent the rotation of the remaining left hemiliver.
I. Initial Access, Exposure, and Exploration
The procedure begins with a right subcostal incision, followed by the division of the falciform and round ligaments.
Retraction: A retractor (such as a Thompson retractor) is installed to provide optimal exposure of the site.
Exploration: The abdomen is explored to determine tumor number and size.
Resectability Assessment: Intraoperative ultrasound is utilized to evaluate the tumor's location in relation to vascular structures. This assessment forms the basis for the definitive decision regarding the resectability of the lesion.
II. Mobilization and Anatomical Identification
Mobilization of the right lobe involves dissecting the anterior leaf of the coronary ligament and the right triangular ligament.
Surgical Maneuvers
Retraction: The assistant retracts the liver inferiorly and to the left using a gauze swab.
Organ Protection: The stomach and duodenum should be protected by removing the Thompson finger blade during this phase.
Vascular Protection: Care must be taken to protect the phrenic vessel and ensure hemostasis from phrenic collaterals.
Cholecystectomy: The gallbladder is removed as part of the mobilization process.
Vascular Variations
During the identification of the suprahepatic vena cava and the right hepatic vein, surgeons must be aware of common anatomical variations:
III. Hilar Preparation and Vascular Transsection
Arterial and Portal Control
The preparation of hilar structures requires the division of the hepatoduodenal ligament to the left of the cystic duct.
Arterial Patency Test: A "bulldog" clamp is placed on the right branch of the hepatic artery to test the patency of the arterial blood supply to the left hemiliver, which is assessed by palpation.
Right Hepatic Artery: Once anatomy is confirmed, the right branch is divided between ties.
Right Portal Vein:
A small branch to the caudate process is often ligated to facilitate a safe ligation of the right portal vein.
The vein is freed and transsected using silk ligatures, a vascular stapler, or a running Prolene 6-0 suture.
Following this, a demarcation line becomes visible between the left and right hemiliver.
Hepatic Vein Management
Short Hepatic Veins: These are divided between ties on the right side. Caution: Clips should be avoided on the caval side, as they may detach once post-operative CVP increases.
Right Hepatic Vein: This is separated from the mid and left hepatic veins. Transsection is performed using a vascular stapler or a vascular spoon clamp combined with silk ligatures and large clips. The caval side is secured with a running 4-0 polypropylene suture.
IV. Parenchymal Transsection and Hemostasis
The transsection of the liver parenchyma follows the established demarcation line.
Stay Sutures: Two 2-0 silk stay sutures are placed at the inferior margin of the liver on either side of the demarcation line.
CVP Regulation: Surgeons must verify with the anesthesiologist that CVP is low (below 3 mm Hg) before incising the liver capsule with diathermy.
Dissection: Dissection proceeds posteriorly and then inferiorly, preserving the mid hepatic vein. All identified bile ducts or vessels larger than 3 mm are ligated and divided.
Bile Duct Division: In the hilum, the right bile duct is divided away from the main confluence, above the caudate process.
Post-Transsection Protocol
Compression: A gauze swab is placed on the resection surface with slight compression for several minutes to manage diffuse bleeding.
Suture-Ligation: Specific bleeding sites on the cut surface are suture-ligated.
Bile Leak Inspection: The resection site is inspected for bile leaks. Leaks are overseen with PDS 4-0 or 5-0. Methylene blue may be injected into the common bile duct to assist in leak identification.
Final Stability: The falciform ligament is reattached to prevent rotation of the left hemiliver. The abdomen is closed without drainage.
V. Surgical Best Practices: "Tricks of the Senior Surgeon"
The document highlights several critical strategies for optimizing outcomes during a right hemihepatectomy:
Exposure: Optimal retractor placement is the most important factor for evaluation and surgical success.
Early Coordination: The request for low CVP should be made early in the procedure to significantly reduce overall blood loss.
Ligature Reinforcement: If using a ligature for the right hepatic vein on the liver side, adding a large clip to the ligature prevents bleeding.
Manual Stabilization: If bleeding occurs despite clips, the right hepatic vein should be compressed with a finger while continuing on the caval side.
Parenchymal Dissection: The surgeon should hold the right hemiliver with their left hand or a band for optimal exposure and protection of the cava during transsection.
