Young K. Hong, MD
Right Hepatectomy
Procedure Overview
Right hepatectomy is a formal anatomic resection of right lobe of liver. The inflow and outflow of the liver blood supply is controlled prior to parenchymal transection. Here we outline the steps for right hepatectomy.
INDICATIONS & OBJECTIVES:
- Primary hepatocellular carcinoma
- Colorectal liver metastasis
- Metastatic neuroendocrine tumor
- Primary intrahepatic cholangiocarcinoma
- Hilar cholangiocarcinoma
- Symptomatic giant hemangioma
Relevant Anatomy
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Pre-operative Patient Care
Typical recommendations for pre-operative care may include, but are not limited to, any of the following:
- Cardiac evaluation
- Pulmonary evaluation
- Prehabilitation before surgery as indicated (such as diabetic control (A1c), stop smoking, weight loss)
- Optimize nutrition
- Carbohydrate load except for diabetic patient
Prep & Patient Positioning
Common patient positioning:
- Typically, the patient is placed in the supine, depending on surgeon preference
- Arms out to allow access for anesthesia for additional lines
- Surgeon can be on either side of the patient
- Assistant is opposite from surgeon
- IMPORTANT: Patient secured to the table
- OG (oral-gastric) tube
- Venous compression boots
- Foley catheter
Operative Steps
Access
Access
Incision:
- Modified Makuuchi incision is utilized to maximize visibility while lower pain compared to subcostal incision, especially after TAP block (anesthetic/nerve block) along the lateral incision.
- Thompson bar or a similar retractor on patient’s right side should have lower bar lowered as much as possible to allow in-line view of vena cava during mobilization portion.
Mobilize Liver:
- Take down the falciform ligament and bilateral coronary/triangular ligaments for optimal mobilization to minimize stress on left liver when retracting the liver.
- Retrohepatic vena cava mobilization should take caution to ligate small short retrohepatic vein attachments.
- Retrohepatic suspensory ligament or Makuuchi ligament is transected to visualize right hepatic vein insertion in order to encircle the vessel.
Inflow Control:
- Dissect portal hilum to isolate the right hepatic artery and right portal vein.
- Be sure to test clamp and confirm blood flow to left liver prior transection
Outflow Control:
- Right hepatic vein is encircled and transected with vascular stapler, such as ECHELON FLEX™ Powered Vascular Stapler.
- Important to transect the Makuuchi ligament to visualize the insertion of right hepatic vein
Repair
Repair
Parenchymal Transection:
- Using an energy device, transect along the line of demarcation of ischemic liver.
- Pringle maneuver is utilized during transection – important to have operative team track time on pringle maneuver and allow adequate time to re-pringle.
- A combination of bipolar, ultrasonic and mechanical methods utilizing devices such as ENSEAL™ X1 Curved Jaw Tissue Sealer, are used for dissection to transect the liver.
- Important to coordinate with anesthesia to minimize fluid resuscitation to prevent retrograde flow within liver and minimize hemorrhage.
- Frequent use of ultrasound throughout case is critical and must be familiar with ultrasound technique.
Closure
Closure
- Resuspend the falciform ligament to minimize complication of liver torsion after hepatectomy.
- Place figure of eight synthetic absorbable suture such as #0 Vicryl™ Plus Antibacterial Suture to approximate the umbilicus prior closing the lateral incision.
- Fascia is closed in a running fashion using a synthetic absorbable suture such as #1 PDS™ Plus Antibacterial Suture.
- Skin closure is performed using a synthetic absorbable suture such as such as Monocryl™ Plus Antibacterial sutures and a topical skin adhesive such as Dermabond™ Prineo Skin Closure System.
Post-operative Patient Care
Typical recommendations for post-operative care may include, but are not limited to, any of the following:
- Typical discharge instructions consist of pain management.
- ERAS protocol such as early feeding, ambulation, remove foley catheter, non-narcotic pain control.
Additional resources
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