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Hepatic trisegmentectomy and other liver resections

Starzl, TE and Bell, RH and Beart, RW and Putnam, CW (1975) Hepatic trisegmentectomy and other liver resections. Surgery Gynecology and Obstetrics, 141 (3). 429 - 437. ISSN 0039-6087

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Abstract

Trisegmentectomy, extended right hepatic lobectomy, is the removal of the true right lobe of the liver in continuity with most or all of the medial segment of the left lobe. Some important features of the operation have not been well described previously. To perform trisegmentectomy, safely, a fusion of liver tissue covering the umbilical fissure at the level of the falciform ligament must first be split open in many patients. The left branches of the portal triad structures are mobilized from the undersurface of the liver nearly to but not into the umbilical fissure. The blood supply and duct drainage of the medial segment originate within the umbilical fissure and feed back toward the right side buried in liver substance. They are found with blunt dissection just to the right of the flaciform ligament, encircled and ligated. Failure to appreciate this switch back anatomic arrangement may lead to injury of the blood supply or biliary drainage of the residual lateral segment. Parenthetically, the mirror image operation of lateral segmentectomy could result in devascularization of the medial segment if dissection and ligation were performed within the umbilical fissure instead of well to the left of this landmark. In most trisegmentectomies, the left portion of the caudate lobe is not removed. This small piece of tissue is interposed between the lateral segment and the inferior vena cava into which it drains by small tributaries. If the left portion of the caudate lobe is to be excised, it is necessary to ligate the last two posteriorly running branches before the main left trunks of the portal triad structures reach the umbilical fissure. Once this step is taken and if the caudate removal is completed, the remaining lateral segment usually has only one remaining outflow, that of the left hepatic vein. The other principles of trisegmentectomy are the same as with less radical subtotal hepatic resection. These include vascular suture closure of the main outflow veins, avoidance of parasegmental planes that leave behind a strip of devitalized tissue, preservation of intersegmental or interlobar veins, omission of techniques that sew shut or otherwise cover the raw surface of the remnant and provision of adequate drainage of dead space. After trisegmentectomy and also after true lobectomy, this last objective is usually met by leaving part of the operative incision open. Using thse guidelines, there has been no mortality with 27 hepatic resections carried out since 1963, including 14 trisegmentectomies.


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Details

Item Type: Article
Status: Published
Creators/Authors:
CreatorsEmailPitt UsernameORCID
Starzl, TEtes11@pitt.eduTES11
Bell, RH
Beart, RW
Putnam, CW
Centers: Other Centers, Institutes, or Units > Thomas E. Starzl Transplantation Institute
Date: 1 December 1975
Date Type: Publication
Journal or Publication Title: Surgery Gynecology and Obstetrics
Volume: 141
Number: 3
Page Range: 429 - 437
Institution: University of Pittsburgh
Refereed: Yes
ISSN: 0039-6087
Other ID: uls-drl:31735062109578, Starzl CV No. 356
Date Deposited: 08 Apr 2010 17:06
Last Modified: 05 Dec 2017 17:00
URI: http://d-scholarship.pitt.edu/id/eprint/3742

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