Step-by-step isolated resection of segment 1 of the liver using the hanging maneuver
Executive Summary
This document details a surgical technique variation for the isolated resection of segment 1 (Spiegel’s lobe) of the liver. Historically, the caudate lobe's deep anatomical position and proximity to major vascular structures—including the inferior vena cava (IVC) and the hepatic veins—have made isolated resections technically challenging.
The described approach utilizes a modified "liver hanging maneuver" to facilitate resection with minimal mobilization and without the need for a Pringle’s maneuver (portal vein clamping). Key outcomes from a four-case series include:
Zero blood transfusions required during or after the operations.
Negative resection margins (R0) achieved in all patients.
Reduced surgical trauma through direct exposure and precise parenchymal transection using a Cavitron Ultrasonic Surgical Aspirator (CUSA).
Efficient recovery, with a mean postoperative hospital stay of five days.
Anatomical Context of the Caudate Lobe
The caudate lobe is a frequent site for primary liver tumors and solitary metastases. For surgical purposes, it is divided into three distinct parts:
Spiegel’s Lobe (Couinaud’s Segment 1): Located on the left.
Paracaval Portion (Couinaud’s Segment 9): Located on the right, encircling the side of the IVC.
Caudate Process.
The canal of Arantius (ligamentum venosum) serves as the anatomical landmark defining the boundary between segments 1 and 9.
Vascular and Biliary Characteristics
Inflow: Most arterial branches arise from the left hepatic artery, though some originate from the right. Portal vein branches primarily come from the main left portal vein, but can also stem from the right vein or the bifurcation.
Outflow: The caudate lobe drains directly into the IVC via several small accessory hepatic veins and 1–3 sizable proper hepatic veins.
Biliary Drainage: Spiegel’s lobe typically drains into the left hepatic duct.
The Three-Step Surgical Technique
The procedure is initiated via a right subcostal abdominal incision and intraoperative ultrasonography to confirm vascular anatomy and tumor margins.
Step 1: Control of Inflow
The blood supply is controlled at the base of the umbilical fissure. Vessels for segment 1 originating from the left portal vein and left hepatic artery are identified and sectioned. Biliary radicals are ligated at this stage or during the parenchymal section.
Step 2: The Liver Hanging Maneuver and Parenchymal Section
The core of the technique involves creating a guide for the transection plane:
IVC Dissection: The anterior surface of both the suprahepatic and infrahepatic IVC is exposed.
Tape Insertion: A long, curved Kelly clamp is passed cranially along the anteromedian surface of the IVC, emerging between the right hepatic vein (RHV) and middle hepatic vein (MHV). A 1 cm wide, 40 cm long cloth tape is seized and pulled through this tunnel.
Liver Elevation: The tape is passed behind the common trunk of the MHV and left hepatic vein (LHV) and pulled upward. This facilitates direct exposure of segment 1 and protects the IVC.
Transection: Two traction stitches are placed on the inferior edge of the caudate lobe to delimit the resection line. The parenchyma is divided using a CUSA, following the path of the tape.
Step 3: Retrohepatic Vein Management
Once the parenchymatous section is complete, the short hepatic veins draining into the IVC are exposed. Segment 1 is moved to the left, allowing for individual ligation and division of these veins. The resection is finalized by cutting the hepatocave ligament surrounding the IVC.
Clinical Outcomes and Patient Data
The following table summarizes the clinical experience with four patients (three men, one woman, aged 56–73) who underwent this isolated resection.
Note: CCR denotes Colorectal Cancer.
Technical Advantages and Discussion
The authors argue that this modified hanging maneuver offers several critical advantages over traditional approaches:
Avoidance of Global Ischemia: Unlike other proposed techniques, this method does not require the Pringle’s maneuver. This prevents ischemic injury to the remaining liver, which is particularly beneficial for patients with cirrhosis or those who have undergone chemotherapy.
Reduced Vascular Risk: The upward tension provided by the tape and traction stitches opens the section line, facilitates hemostasis by compressing small vessels, and significantly reduces the risk of accidental injury to the IVC and middle hepatic vein.
Minimal Tumor Manipulation: The approach avoids intense manipulation or excessive mobilization of the liver, which theoretically reduces the risk of tumor spillage or dissemination.
Precise Margins: By using the tape as a guide for the transection plane, the surgeon can maintain a straight line from the anterior surface of the liver to the IVC, ensuring adequate tumor-free margins (R0).
Conclusion
The isolated resection of segment 1 using the hanging maneuver is a regulated, three-step technique that allows for the removal of lesions in the caudate lobe without sacrificing other liver segments. By prioritizing initial inflow control and utilizing the tape-assisted parenchymal section, surgeons can achieve successful oncological outcomes with minimal blood loss and an acceptable surgical timeframe.
