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Review
. 1989 May;26(5):281-379.
doi: 10.1016/0011-3840(89)90022-1.

The changing face of hepatic resection

S Iwatsuki  1 , D G Sheahan, T E Starzl
Affiliations
Review

The changing face of hepatic resection

S Iwatsuki et al. Curr Probl Surg. 1989 May.
No abstract available

PubMed Disclaimer

Figures

FIG 1
FIG 1
The liver is divided into the right and left lobes by a sagittal plane (A). The left lobe is further divided into the lateral and medial segments by another sagittal plane (B). The right lobe is divided into the anterior and posterior segments by a coronal plane (C).
FIG 2
FIG 2
Couinaud’s eight hepatic segments (subsegments). The four segments shown in Figure 1 are each further divided into two subsegments, and each segment is numbered from I to VIII.
FIG 3
FIG 3
For practical purposes, there are only four surgical units (segments), and five kinds of anatomical resections are commonly used.
FIG 4
FIG 4
Schematic drawing of common variations of hepatic arterial blood supply. A = artery, PV = portal vein, SMA = superior mesenteric artery.
FIG 5
FIG 5
Intrahepatic distribution of the hepatic arteries and bile ducts. (1) Common hepatic artery, (2) right hepatic artery, (3) posterior segmental artery, (4) superior posterior area artery, (5) inferior posterior area artery, (6) anterior segmental artery, (7) superior anterior area artery, (8) inferior anterior area artery, (9) left hepatic artery, (10) medial segmental artery, (11) superior medial area artery, (12) inferior medial area artery, (13) lateral segmental artery, (14) superior lateral area artery, (15) inferior lateral area artery, (16) arteries to the caudate lobe.
FIG 6
FIG 6
Intrahepatic distribution of the portal vein: RPV = right portal vein, LPV = left portal vein, A = pars transversus, B = pars umbilicus.
FIG 7
FIG 7
Prevailing pattern of hepatic venous drainage.
FIG 8
FIG 8
Schematic drawings of five truly anatomical resections and a nonanatomical resection.
FIG 9
FIG 9
Commonly used incisions for hepatic resection.
FIG 10
FIG 10
Preliminary mobilization of the right hepatic lobe. (From Starzl TE: Experience in Hepatic Transplantation. Philadelphia, WB Saunders Co, 1969, p 51. Used by permission.)
FIG 11
FIG 11
Several small short hepatic veins are ligated and divided as they enter the vena cava. The right hepatic vein is divided between vascular clamps and oversewn with vascular sutures. I.v.c. = inferior vena cava. (From Starzl TE et al: Surg Gynecol Obstet 1975; 141:435. Used by permission.)
FIG 12
FIG 12
Intraoperative examination of hepatic arterial blood supply. (From Starzl TE: Experience in Hepatic Transplantation. Philadelphia, WB Saunders Co, 1969, p 52. Used by permission.)
FIG 13
FIG 13
Devascularization of the right lobe is completed. The bifurcation of the bile duct is almost always the most superior structure and is often inside the liver. I.v.c. = inferior vena cava; G.b. = gallbladder. (From Starzl TE et al: Surg Gynecol Obstet 1975; 141:431. Used by permission.)
FIG 14
FIG 14
Posterior approach in dissecting the bifurcation of the portal vein. I.v.c. = inferior vena cava. (From Starzl TE et al: Surg Gynecol Obstet 1975; 141:432. Used by permission.)
FIG 15
FIG 15
Nearly completed division of fine branches from the transverse part of portal triad structures. The branches to the caudate lobe should be preserved unless all of the caudate lobe is to be removed. The tissue bridge is being broken down to permit access to the umbilical fissure. (From Starzl TE et al: Surg Gynecol Obstet 1975; 141:433. Used by permission.)
FIG 16
FIG 16
After preliminary mobilization the right lobe is gently retracted anteriorly and to the left. The entire length of the retrohepatic vena cava is exposed by careful dissection. I.V.C. = inferior vena cava; R.H.V. = right hepatic vein. (From Starzl TE: Experience in Hepatic Transplantation. Philadelphia, WB Saunders Co, 1969, p 116. Used by permission.)
FIG 17
FIG 17
Structures feeding back from the umbilical fissure to the medial segment of the left lobe. A, these structures are found in the liver substance just to the right of the falciform ligament and umbilical fissure. Note that hepatic tissue bridge has been broken down. B, the three segments of the specimen are now devascularized. (From Starzl TE, et al: Surg Gynecol Obstet 1975; 141:434. Used by permission.)
FIG 18
FIG 18
Nearly completed liver transection for right trisegmentectomy along exact line of color demarcation. The last major structure to be encountered is the middle hepatic vein. Injury to the left hepatic vein must be avoided. I.v.c. = inferior vena cava, C.d. = common bile duct, H.a. = hepatic artery, P.v. = portal vein. (From Starzl TE et al: Surg Gynecol Obstet 1975; 141:436. Used by permission.)
FIG 19
FIG 19
Control of right hepatic vein from within the liver nearly at the end of liver transection. I.v.c. = inferior vena cava. (From Starzl TE et al: Surg Gynecol Obstet 1980; 150:2. Reproduced with permission.)
FIG 20
FIG 20
Exposure of the left hilar structures is accomplished by retracting the lateral segment of the left lobe anteriorly and to the right. If the left portion of the caudate lobe is removed, it must be dissected from the vena cava, and a few small hepatic veins must be ligated. (From Starzl TE et al: Surg Gynecol Obstet 1982; 155:4. Used by permission.)
FIG 21
FIG 21
Completion of the left hilar dissections and divisions. The caudate lobe is spared. Note the color demarcation and the posterior incision along the obliterated ductus venosus. (From Starzl TE et al: Surg Gynecol Obstet 1982; 155:4. Used by permission.)
FIG 22
FIG 22
Superior to inferior scalping of the anterior segment of the right lobe. Note that the dissecting finger is kept anterior to the right hepatic vein, the left and middle hepatic veins having been ligated or sutured. (From Starzl TE et al: Surg Gynecol Obstet 1982; 155:5. Used by permission.)
FIG 23
FIG 23
Further development of plane between the anterior and posterior segment of the right lobe of the liver. (From Starzl TE et al: Surg Gynecol Obstet 1982; 155:5. Used by permission.)
FIG 24
FIG 24
Alternative approach with which the anterior segment is scalped from the hilus of the liver to the diaphragm. (From Starzl TE et al: Surg Gynecol Obstet 1982; 155:6. Used by permission.)
FIG 25
FIG 25
Operative field after completion of left trisegmentectomy. (From Starzl TE et al: Surg Gynecol Obstet 1982; 155:6. Used by permission.)
FIG 26
FIG 26
Giant cavernous hemangioma
FIG 27
FIG 27
Multiple hepatic adenomas. Numerous lesions of irregular dimensions with focal hemorrhagic necrosis (lower right).
FIG 28
FIG 28
Hepatic adenoma. Narrow trabecular pattern of hepatocytes with vascular channels loosely separated from normal liver tissue (lower left) shows dark portal triads. Hematoxylin-eosin; ×20.
FIG 29
FIG 29
Focal nodular hyperplasia. Segment of lesion with central white scar. The contiguous liver is normal.
FIG 30
FIG 30
Focal nodular hyperplasia. Irregular nodules of mature hepatocytes separated by irregular bands of fibrosis containing irregularly sized vascular channels and chronic inflammatory cells. Hematoxylin-eosin; ×20.
FIG 31
FIG 31
Mesenchymal hamartoma, Well-circumscribed mucoid-appearing lesion with central white scar tissue.
FIG 32
FIG 32
Caroli’s disease. Marked fibrosis of focally dilated intrahepatic biliary tree with numerous pigment stones and prominent biliary cirrhosis.
FIG 33
FIG 33
Caroli’s disease. Dilated bile duct with partially denuded epithelial lining surrounded by secondary organized fibrosis and chronic inflammation. Hematoxylin-eosin; ×50.
FIG 34
FIG 34
Squamous cyst of liver. Cyst is lined by mature squamous epithelium with subjacent fibrous wall separating it from liver parenchyma. Hematoxylin-eosin; ×50.
FIG 35
FIG 35
Squamous cell carcinoma of liver. Irregular sheets of squamous epithelium with focal keratin pearl formation. Hematoxylin-eosin; ×125.
FIG 36
FIG 36
Echinococcal cyst. Large cyst at right with contiguous smaller cysts embedded in fibrous tissue reflecting prior rupture of cyst.
FIG 37
FIG 37
Metastatic colon carcinoma. Two separate lesions, both abutting capsule. The resecting margin (below) is uninvolved by tumor.
FIG 38
FIG 38
Hepatocellular carcinoma. Large irregularly nodular tumor with multiple areas of hemorrhage, necrosis, cystic degeneration, and fibrosis.
FIG 39
FIG 39
Hepatocellular carcinoma, clear cell type. This lesion must be differentiated from other clear cell carcinomas, especially renal and adrenal. Hematoxylin-eosin; ×125.
FIG 40
FIG 40
Hepatocellular carcinoma. Two types of differentiation are present. The lower right shows trabecular and pseudoglandular (adenoid); the upper left shows clear cell differentiation. Hematoxylin-eosin; ×125.
FIG 41
FIG 41
Hepatocellular carcinoma, giant cell type. Hematoxylin-eosin; ×125.
FIG 42
FIG 42
Hepatocellular carcinoma. Two types of differentiation are present: the lower right shows trabecular tumor; the upper left shows focal glandular differentiation. Hematoxylin-eosin; ×50
FIG 43
FIG 43
Fibrolamellar heptocellular carcinoma: Large (20-cm) tumor arising in normal liver (top left) with extensive radiating scar formation (center right).
FIG 44
FIG 44
Fibrolamellar hepatocellular carcinoma. Large oncocytic hepatocytes in irregular cords separated by acellular lamellated collagen. Trichrome; ×125.
FIG 45
FIG 45
Neuroendocrine carcinoma. Note palisading fibrovascular stroma and uniform appearance of epithelial cells. Hematoxylin-eosin; ×125.
FIG 46
FIG 46
Infiltrating cholangiocarcinoma. Note marked desmoplasia and irregular gland formation. Hematoxylin-eosin; × 125.
FIG 47
FIG 47
Cholangiocarcinoma, in situ and infiltrating. Note the normal appearance of left side of largest duct with abrupt change to neoplastic epithelium on the right. The infiltrating glandular component with prominent desmoplasia is evident. Hematoxylin-eosin; × 125.
FIG 48
FIG 48
Hepatoblastoma. The darker embryonal cells are present at top left; the paler fetal cells are present throughout the remainder of the picture. Hematoxylin-eosin; × 125.
FIG 49
FIG 49
Leiomyosarcoma of liver. The top left corner shows well-differentiated tumor; the remainder is undifferentiated. Hematoxylin-eosin; × 125.
FIG 50
FIG 50
Metastatic leiomyosarcoma of colon. Multiple irregular tumor nodules without specific distinguishing features. The resection margin (lower right) is not involved by tumor.
FIG 51
FIG 51
Angiosarcoma of liver. Irregular anastomosing channels lined by pleomorphic endothelial cells that also infiltrate into sinusoids between liver plates. Darker material at top left is thorotrast. Hematoxylin-eosin; × 125.
FIG 52
FIG 52
Epithelioid hemangioendothelioma. Multiple discrete nodules of varying size with surface umbilication occurring in otherwise normal liver.
FIG 53
FIG 53
Epithelioid hemangioendothelioma. Irregular centriacinar extension of tumor around periportal zones (top central) with less cellular tumor in deeper regions (bottom right). Hematoxylin-eosin; ×50.
FIG 54
FIG 54
Giant cavernous hemangioma with central necrosis
FIG 55
FIG 55
Spontaneous rupture of multiple liver cell adenoma. Note massive hemoperitoneum.
FIG 56
FIG 56
Polycystic disease of the liver.
FIG 57
FIG 57
After hepatic resection there was no difference in actuarial survival rates between 123 patients with primary hepatic malignancy and 153 patients with secondary hepatic malignancy.
FIG 58
FIG 58
After hepatic resection the survival rate of patients with fibrolamellar hepatocellular carcinoma was higher (P < .01) than that of patients with nonfibrolamellar hepatocellular carcinoma and higher than with cholangiocarcinoma.
FIG 59
FIG 59
After hepatic resection there was no difference in actuarial survival rates between 118 patients with colorectal metastasis and 35 patients with other metastases.
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