Reglas de Hepatectomias

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W o r l d J . S u r g . 6, 10-24, 1 9 8 2

of Sdrgery

Major and Minor Segmentectomies "R6gl6es" in Liver Surgery

Henri Bismuth, M.D., Didier Houssin, M.D., and Denis Castaing, M.D.

Uni t~ de Ch i ru rg ie H~pa to -Bi l ia i re , F acu l t6 de M6dec ine P a r i s S ud , H6p i ta l P au l Brousse , Vi l le ju i f , F rance

I n d i v i d u a l i z a ti o n o f t h e s e g m e n t a s t h e f u n c t i o n a l a n a t o m i -

c a l u n i t o f t h e l iv e r p e r m i t s t h e p e r f o r m a n c e o f s u r g i c a l

s e g m e n t e c t o m i e s . T h e s e s e g m e n t a l r e s e c ti o n s a r e " r 6 g l 6 e s "

b e c a u s e t h e p l a n e o f c l e a v a g e o f t h e h e p a t i c p a r e n c h y m a

f o l lo w s t h e a n a t o m i c a l s c is s u r a e . F r o m t h e t e c h n i c a l p o i n t

o f v i e w , l i v e r s e g m e n t e c t o m i e s a r e c h a r a c t e r i z e d b y a n

e x c l u s i v e t r a n s p a r e n c h y m a t o u s a p p r o a c h t o t h e v a s c u l a r

p e d i c le s o f t h e s e g m e n t t o b e r e m o v e d . W e h a v e p e r f o r m e d

t h i s t y p e o f s u r g e r y i n 2 2 p a t i e n t s w i t h n o m o r t a l i t y . T h e s e

o p e r a t i o n s a r e i n d i c a t e d i n : ( 1 ) s o m e b e n i g n t u m o r s ; ( 2 )

s o m e l i v e r t r a u m a ; ( 3 ) b i l i a r y o p e r a t i o n s a b o v e t h e h i l u s ,

w h e r e a n t e r i o r r e s e c t i o n o f s e g m e n t I V c a n b e n e c e s s a r y ;

a n d ( 4 ) c a r c i n o m a s o f t h e g a l l b l a d d e r d i s c o v e r e d h i s t o l o g i -

c a l ly a f t e r c h o l e c y s t e c t o m y . L i v e r s e g m e n t e c t o m i e s c a n a l s o

b e i n d i c a te d f o r m a l i g n a n t t u m o r s w h e n t h e l i v e r is c i r r h o t -i c , o r w h e n a n e x t e n d e d r e s e c t i o n i s l ik e l y t o e x p o s e t h e

p a t i e n t t o t h e r i s k o f l i v e r f a i l u r e . I n d e e d , o n e o f t h e m a i n

a d v a n t a g e s o f l i v e r s e g m e n t e c t o m i e s i s t h a t t h e y p e r m i t

a n e c o n o m i c a l b u t s a f e s u r g i c a l r e s e c t i o n o f t h e h e p a t i c

p a r e n c h y m a .

There is some confusion in the world literatureregarding the definition of the anatomical divisionof the liver. Elsewhere in this symposium, thedifferent concepts are explained and a nomencla-ture, that of Couinaud [1], is chosen. According to

Couinaud, a segment is the smallest anatomical unitof the liver (Fig. 1). The segment described byCouinaud corresponds approximately to the sub-segment described by Goldsmith and Woodburne[2]. It is different from the area descr ibed by Hea ley

Reprint requests: Henri Bismuth, H6pitalBrousse, 94800 Villejuif, France.

0364-2313/82/0006-0010 $03.009 1982 Socidt6 Internationale de Chirurgie

Paul

and Schroy [3], which is based upon the biliary

distribution rather than up on the portal distribution.The resection of one of the 8 segments o f the liver

is called a segmentectomy: unisegmentectomywhen 1 segment is removed, plurisegmentectomy

when 2 or more segments are removed. Liversegmentectomies are intermediate procedures be-tween the 4 common hepatectomies and the smallatypical wedge resections. Segmentectomies are"r6gl6es" because they follow exclusively the ana-tomical liver scissurae that separate the differentsegments of the gland. Respect of these scissuraeduring segmental excisions prevents impairment of

the vascularization of the remaining parenchymaand excessive bleeding. A thorough knowledge ofthe anatomical structure of the liver is prerequisiteto the performance of liver segmentectomies.

Liver segmentectomies permit the anatomicalresection of hepatic lesions without the unneces-sary removal of a large amou nt of normal parenchy-ma. They are particularly useful in some benigntumors or posttraumatic lesions; for carcinomas ofthe gallbladder; more rarely for biliary surgeryabove the hilus; for removal of small centralhepatocarcinomas; and for liver resections in cir-rhotic patients.

The purpose of this report is to describe thetechnical aspects of the major and minor liversegmentectomies "r6gl6es." We shall also reviewour experience with various segmental resections in22 patients (Table 1) who underwent this type of

surgery at our hospital betw een 1970 and 1980. Thedifferent indications for operation are given in

Table 2.Liver segmentectomies "r6gl6es" are the best

illustration of the technique of primary intraparen-chymatous approach of the hepatic vessels de-scribed by Ton That Tung [4]. Indeed, since most ofthe left or right liver is conserved, there is no place



H.B i sm uth e t a l . : Se gm e nte c tom i e s i n L i ve r Sur ge r y 11

,o,

B

Fig. 1 . Segm enta t ion of the l ive r accord ing to Cou inaud[1]. A. Sup erior view. Segm ent VIII is visible only on thisview. B. Inferior view. Segment I is vis ible only on thisview.

Ta b l e 1. Major and minor s egmentec tomies " rdgl6es" inl iver su rgery (22 pat ients) .

P rocedure No. of pa t i en t s

Unisegmentec tomiesS e g m e n t e c t o m y I V 7

Ante r ior 6

Comple te 1S e g m e n t e c t o m y V I 1S e g m e n t e c t o m y V I I I 1

P lur i s egmentec tomiesB i s e g m e n t e c to m y V I - V I I 3B i s e g m e n t e c to m y I V - V 6B i s e g m e n t e c to m y V - V I 2T r i s e g m e n t ec t o m y I V - V - V I 2

Ta b l e 2. Indicat ions for l iver segmentectomies (22 cases) .

Indica t ion No. of pa t i en t s

Hepa t i c tumorsBenign 6Mal ignant 6

Gal lb ladder ca rc inom a 5L i v e r t r a u m a 3Bil iary surgery 2

Total 22

w h i c h i s d e s c r i b e d b y T o n T h a t T u n g [ 4 ] , i n a

p a t i e n t w h o h a d a s m a l l h e p a t o c a r c i n o m a c o n f i n e d

t o t h e S p i g e l l o b e .

i n t h e s e t e c h n i q u e s f o r a n e x t r a h e p a t i c v a s c u l a r

l i g a ti o n a t t h e l e v e l o f th e h e p a t i c p e d i c l e . U s u a l l y ,

t h e l i v e r p a r e n c h y m a i s a p p r o a c h e d d i r e c t l y a l o n g

a n a n a t o m i c a l s c i s s u r a w i t h o u t p r e v i o u s l y d i s s e c t -

i n g t h e h e p a t i c p e d i c l e . A t m o s t , i t m a y b e u s e f u l o n

o c c a s i o n to c l a m p t e m p o r a r i l y t h e h o m o l a t e r a l v e s -

s e ls a t t h e h e p a t i c p e d i c l e o r m o r e d i s t a l l y , c lo s e t o

t h e li v er p a r e n c h y m a .

U n i s e g m e n t e c t o m i e s

T h e o r e t i c a l ly , e a c h o f t h e 8 s e g m e n t s o f th e l i v e r

c a n b e r e m o v e d s e p a r a t e l y ( Fi g . 2 ). H o w e v e r , t h e

e l e ct iv e r e s e c t i o n o f s e g m e n t I I o r s e g m e n t I I I h a s

n o p r a ct i ca l v a l u e a n d w e h a v e n o e x p e r i e n c e w i t h

it .

S e g m e n t e c t o m y I ( e x c i si o n o f t h e S p i g e l lo b e )

m a y b e i n d i c a t e d in s o m e l i v e r t u m o r s c o n f i n e d t o

t h e S pi g el l o b e. H o w e v e r , a c c e s s t o s e g m e n t I

u s u a ll y r eq u i r e s a p r e l i m i n a r y l e f t l o b e c t o m y w h i c h

t r a n s f o r m s s e g m e n t e c t o m y I i n to a m a j o r e x t e n d e d

l e ft l o b e c t o m y . W e h a v e p e r f o r m e d t h i s o p e r a t io n ,

S e g m e n t e c t o m y I V

U s u a l l y , o n l y t h e a n t e r i o r a n d m o b i l e p a r t o f s eg -

m e n t I V i s r e m o v e d . T h i s a n t e r i o r p o r t i o n i s l o c a t e d

a n t e r i o r l y to t h e l i v e r h i l u s a n d c o r r e s p o n d s t o t h e

q u a d r a t e l o b e . T h i s l o b e i s l im i t e d t o t h e l e f t b y t h e

u m b i l ic a l f i s s u r e a n d t o t h e r i g h t b y t h e m a i n

s c i s s u r a .

A n t e r io r S e g m e n t e c t o m y I V

o r R e s e c t io n o f Q u a d r a t e L o b e

A n t e r i o r S e g m e n t e c t o m y I V . P e r f o r m e d f o r t h e f i rs t

t i m e b y C a p r i o [ 5], t h i s t e c h n i q u e w a s f u l l y d e -

s c r i b e d b y C h a m p e a u [ 6 ] , w h o e x t e n d e d i t s u s e t o

b i li a ry s u r g e r y b y p r o p o s i n g e i t h e r t h e m o b i l i z a t io n

o r t h e r e s e c t io n o f th e q u a d r a t e l o b e f o r g a i n in g

a c c e s s t o t h e s u p e r i o r p a r t o f t h e b i l i a ry c o n f l u e n c e

(Fig. 3) .

T h r o u g h a m i d l in e o r r i g h t s u b c o s t a l i n c i si o n , t h e

a n t e r io r p a r t o f t h e f a l c i f o r m l ig a m e n t a n d t e r e s

l i g a m e n t u m a r e d i v i d e d ( F i g . 4 ) . T h e t e r e s l i g a m e n -

t u r n i s p u l l e d u p w a r d a n d t h e f i r s t st e p o f t h e



12 W o r ld J . S u rg . Vo l . 6 , No . 1 , Janu a ry 1982

A B

C D

Fig. 2. Unisegmentectomies. A and B. SegmentectomyIV: anterior, of the quadrate lobe (A), and complete (B).C. Segmentectomy VIII. D. Segmentectomy VI.

resection consists of dividing the bridge of paren-

chyma which frequently joins segments III and IV

below the teres ligamentum. This bridge of paren-

chyma is transected by crushing it down with a

Kelly clamp and by electrocoagulation or ligation of

the small vessels. Then, the peritoneum is divided

at the inferior part of the teres ligamentum and 2 or

3 arterial and portal pedicles are dissected to theright of the teres ligamentum. These pedicles are

not systematized and are directed toward the quad-

rate lobe.

The portal pedicles are behind the arterial pedi-

cles, which are superficial. In depth, there is a

fibrous tissue, which constitutes the superior limit

of the teres ligamentum and in which 2 biliary ducts

are usually present.

On the anterior side of the liver and along the

main scissura, the liver is transected up to the

vertex of the hilus. There are no portal branches in

this scissura and the only major vascular elements

requiring ligation are the left branches of the middle

hepatic vein. It is preferable to transect the liver a

little to the left of the main scissura to avoid the

middle hepatic vein.

Posteriorly, at the inferior part of the liver, the

capsule of Glisson is incised in fron t of the peritone-

um of the hilum and some small arterial and portal

branches of the quadrate lobe are ligated and divid-

ed.

Subsequently, a transverse incision of the cap-

sule of Glisson is made at the superior port ion of the

liver, which will join the posterior ends of the right

and left liver transections. This posterior liver tran-

section is performed progressively by crushing

down the parenchyma. During this transection, 3 to

5 branches of the middle hepatic vein are divided.

C o m p l e t e S e g m e n t e c t o m y I V . This procedure is

equivalent to the complete resection of the medial

part of the liver (Fig. 5). Segment IV is removed up

to the anterior part of the vena cava.

The first steps are similar to those performed for

the resection of the quadrate lobe. However, the 2

posteriorly directed parenchymatous transections

are extended up to the vena cava. The middle

hepatic vein, which is usually posteriorly located

close to the vena cava, is not divided during this

complete segmente ctomy IV. Howev er, when the

vein crosses transv ersely the po sterior part of seg-

ment IV to join more anteriorly the left hepatic

vein, it may be necessar y to ligate it, without risk tothe remaining parenchy ma.

As segment IV is just anterior to the Spigel lobe(segment I), the last step of the resection is to

separate these 2 segments. There is no visible

demarcation between the posterior and inferior

parts of segment IV and the anterior and superior

parts of segment I and, for this reason, this last step

can cause bleeding.

After complete resection of segment IV, the liver

is almost split into 2 parts and an approximation of

the 2 parts may be n ecessary to avoid the stomach

and duodenum occupying the wide space between

the right liver and the left lobe.

C a s e Rep o r t s . Patient no. 1 was a 33-year-old

female, on oral contraception for 8 years. During anoperation for an ovarian cyst, she was found to

have a large asymptomatic liver tumor. Angiogra-

phy revealed 2 hypervascu lar lesions: 1 in segment

IV (5 cm in diameter) and 1 in segment VIII (8 cm in

diameter). At reoperation the benign nature of the

tumor was established by frozen section. Because

of the benign character of the lesion and the risk

involved with a large resection, only the anterior

lesion was removed by an anterior segmentectomy

IV, principally for histological diagnosis. Definite

histology was focal nodular hyperplasia. Two years

later, liver ultrasound revealed no modification of

the segment VIII lesion.

Patient no. 2 was a 38-year-old female, on oral

contraception for 8 years, who had a large asymp-

tomatic tumor of segment IV discovered during an

operation for an ovarian cyst. Angiography re-

vealed a large hypervascular lesion in segment IV

and a smaller lesion in segment VIII. At reope ration

the tumor (15 cm in diameter), which was an

hemangioma, was surgically removed by an anteri-

or segmentec tomy IV. The other hemang ioma (7 cm

in diameter) was treated by intraoperative emboli-

zation of the right paramedian artery. One year



H . Bi smut h e t a l . : Se g m e nt e c t o m i e s i n L i v e r Sur g e r y 1 3

Fig. 3 . Ante r io r s egm entec tom y IV or re s ec t ion o f the quadra te lobe . T he d i f fe ren t s t eps o f the t echn ique : (1) Open ing o fthe umbi l i ca l f i s su re ; (2 ) open ing o f the an te r io r p a r t o f the m a in s c i s s u ra ; (3 ) liga t ion o f the por ta l p ed ic le s en te r ing thep o s t e r i o r p a r t o f th e q u a d r a t e l o b e ; a n d ( 4) t r a n s v e r s e t r a n s e c t io n o f th e p a r e n c h y m a .

Fig . 4 . Ante r io r s e gm ente c tom y IV. A . E xp os u re by d iv i s ion o f the fa lc i fo rm l igament . B . T rans ec t io n o f the b r idge o f thep a r e n c h y m a f re q u e n t l y f o u n d b e l o w t h e r o u n d l i ga m e n t . C . E x p o s u r e o f th e v e s s e l s b y o p e n i n g t h e i n f e r i o r s u r f a ce o f t h ecen t ra l pa r t o f the round l igament . D . Sp l i t t ing o f the pa re nch ym a a long the umbi l i ca l f i s s u re. E . T ra ns v e rs e t ran s ec t ion o fthe pa ren chy ma wi th l iga tion o f the hepa t i c ve ins .



14

I I

F i g . 5. Complete segmentectomy IV.

W o r l d J . S u r g . V o l . 6, N o . 1 , J a n u a r y 1 9 8 2

later, liver scan revealed no modification of the

remaining tumor.

Patient no. 3 was a 27-year-old female who was

discovered to have an enlarged liver following

childbirth; angiography revealed a hypervascular

lesion of segment IV (Fig. 6). At operation, a focal

nodular hyperplasia (8 cm in diameter) was diag-

nosed by frozen section and the anterior part of

segment IV was removed. Seven years later, liver

scan was normal.

Patient no. 4 was a 40-year-old male admittedwith jaundice and hepato megaly (Fig. 7). Liver

scintiscan showed a defect at the level of the hilus.

Alpha-fetoprotein was elevated. At operation, the

tumor (3 cm • 4 cm) was located at the posterior

part of the quadrate lobe invading the anterior wall

of the biliary confluence. The hepatoca rcinomato us

nature of the tumor was established by frozen

section. As this small hepatocarcino ma was just in

the middle of the quadrate lobe, equidistant from

the umbilical fissure and from the main scissura, no

clear choice could be made between a right extend-

ed hepatectomy and a left hepatectomy. From the

carcinological point of view, a similar tumoral exci-

sion could be done with less risk by a resection of

the quadrate lobe. This was performed en bloc with

the biliary confluence. The biliary reconstruction

was achieved using a double bilioenteric anastomo-

sis on a Roux-en-Y loop. Postoperative course was

complicated by a wound sepsis. The patient died 3

years later from tumor recurrence.

Patient no. 5, a 40-year-old male, was admitted

for persistent jaundice due to a stenosis of the

biliary confluence, which had been discovered at aprevious operation and treated by biliary stenting.

Clinical history, x-ray and histology suggested a

sclerosing cholangitis. At reoperation, a resection

of the quadrate lobe was performed to establish a

double cholangioenteric anastomosis on the b i l i a ryducts of segments II and V. Histo logy of the wall of

the biliary stenosis was compatible with a scleros-

ing cholangitis. The postoperative course was

marked by gastrointestinal bleeding 9 days after

operation. One year after operation, cholestasis

was markedly decreased. The patient died three

years later.



H. Bismuth et al.: Segmentectomies in Liver Surgery 15

Fig. 6. Patient no. 3. Angiogram of a focal nodularhyperplasia located in the anterior part of segment IV.The tumoral arteries come from the right (rb) and left (lb)

branches of the hepatic artery.


for recurrent jaundice due to a stenosis of the biliary

confluence, discovered at a previous operation and

treated by biliary dilatation. Clinical history and x-

ray suggested a sclerosing cholangitis. At opera-

tion, a resection of the quadrate lobe was perfor med

to establish a double intrahepatic cholangioenteric

anastomosis to ensure the biliary diversion of the 2

livers (Fig. 8). Histology of the wall of the biliary

stenosis was compatible with a sclerosing cholangi-tis. The patient died 61/2 years later because of

intrahepatic tumoral spread.

Patient no. 7 was a 10-year-old boy, admitted

complaining of fever and h epatomegaly. Liver angi-

ography revealed a large hypervascularized mass

supplied by the left and right branches of the

hepatic artery, and occupying the middle part of the

liver. At operation, a huge tumor (10 cm • I0 cm)occupied segment IV, extending to the suprahepatic

vena cava (Fig. 9). A complete segmentectomy IV

was performed. This lesion was reported as hamar-

toma. Three years later, clinical examination and

liver ultrasound were within normal limits.

Segmentectomy VI

Segment VI (Fig. 10) is anterior to the level of the

hilus and is located to the right of the right lateral

scissura. Its resection alone is rarely indicated.

Through a right subcostal incision, the posterior

attachments of the liver are divided to permit its

mobilization and exteriorization. Then, the liver

parenchyma is transected along the right lateral

scissura which starts at the mid point between the

gallbladder and the right extremity of the liver and

ends at the level of the vena cava.

During a segmentectomy VI, this transection is

conducted up to the level of the hilus. At that point,

the liver is transected transversely toward its right

lateral side. During this transection, the anterior

part of the right hepatic vein, which is superiorlylocated, is found and divided. Just below, the portalpedicle of segment VI is ligated and divided. Care

must be taken to avoid ligation of the portal pedicle

of segment VII which has a recurrent course direct-

ed toward the posterior part of the liver.

Case Report. Patient no. 8 was a 49-year-old female

with liver cirrhosis, admitted following an episode

of intra-abdominal bleeding. Alpha-fetoprotein test

results were negative and a severe liver insufficien-

cy was detected. Angiography revealed an hyper-

vascular lesion of segment VI compatible with a

hepatocarcinoma. At operation, the excision of the

tumor was performed by a segmentectomy VI. Thepatient had a stormy postoperative course with

severe hepatic failure, jaundi ce, ascites, and severe

disturbances of the coagulation factors. She recov-

ered from these complications and died after 1 year

from massive bleeding associated with esophageal

varices. Retrospective analysis of the postoper ative

course suggests that a larger hepatect omy, such as a

right hepatectomy, would surely have precipitated

fatal postoperative hepatic failure.

Segmentectomy VIII

Segmentectomy VIII (Fig. 11) consists of the resec-

tion of the superior part of the right paramedian

sector which is located at the superior and posterior

part of the liver. It is connected with the intrahepa-

tic vena cava and with segment I on the midline.

These connections are complex and render the

resection of segment VIII a difficult procedure.

Ton That Tung [4] advocates this liver resection

for the chronic liver abscesses often situated in this

part of the liver. He reported having performed this

segmentectomy in 10 cases. He has given a precise

description of this technique.Segment VIII is limited anteriorly by a tr ansverse

line located at the level of the hilus, and posteriorly

by the right coronary ligament. This segment has no

base and is placed like a wedge between the right

lateral scissura and the main scissura.

Through a right subcostal incision, the falciform

and right coronary ligaments are divided. To reduce

blood loss, the hepatic pedicle can be clamped.

Afterward, the right lateral and main scissurae are

transected from the superior lip of the insertion of

the right coronary ligament, posteriorly, up to the

level of the hilus, anteriorly.



16 World J. Surg. Vol. 6, No. 1, January 1982

umbilicalcissure

Fig . 7A. Pa t i en t no . 4 . Ope ra t iv e v iew o f a sma l l hepa toca rc ino ma loca ted in the pos te r io r pa r t o f the quadra te lobe . B .Ope ra t ive v iew o f the exc i s ion o f the quadra te lobe . T he two he pa t i c duc t s opene d by the re s e c t ion o f the b i l i a ry

conf luence invaded by the ca rc inoma a re c l ea r ly v i s ib le .

J

Fig . 8 . Pa t i en t no. 6 . An te r io r re s ec t ion o f s egmen t IV fo r the pe r fo rmanc e o f a doub le in t rahepa t i c cho la ng ioen te r i c

anas tomos i s .



H . Bismuthet a l.: Segmentectomies n Liver Surgery 17

Fig. 9. Patient no. 7. Complete segmentectomy IV for a huge hamartoma occupying the middle part of the liver. Theaperture is limited on the left by the umbilical fissure and on the right by the main portal scissura. The tumor came close tothe inferior vena cava which is partially exposed.

~ b

!~:~:~::::::~:

i : : : : ~ : ~

Fig. 10. Segmentectomy VI. Fig. 11. Segmentectomy VIII.

These 2 lateral planes of cleavage are joined by 2

transverse transections along the superior lip of the

insertion of the coron ary ligament, posteriorly, and

along the posterior part of the hilus, anteriorly.

Along these lines of transection, the par enchy ma

is crushed and divided. During the posterior tran-section, the hepatic veins of segment VIII are

divided. The first one goes to the middle hepatic

vein and it is posteriorly located to the left, close to

the posterior triangle of insertion of the falciform

ligament. The second one goes to the right hepatic

vein and is posteriorly located to the right. Care

must be taken to confine the liver resection betwe en

the right and the middle hepatic veins. Segment

VIII is then lifted upward, using stay sutures to

allow the palpation and division of the vertical

portal pedicles. If the portal pedicles of segment I

are located too posteriorly, it may be necessary

to divide them to approach the pedicles of

segment VIII.

Case Report. Patient no. 9, a 40-year-old female,

was admitted with persistent intraperitoneal bleed-

ing 2 days after a liver trauma for which she hadalready been operated on in an other hospital. Angi-

ography revealed an extravasation of the contrast

medium at the level of segment VIII. At operation,

disruption of the upper part of the liver and necrosis

of the superior part of the right liver were found.

Resection of the necrotic parenchyma ended in a

segmentectomy VIII which, howeve r, was not

"rdglde" along all the lines of the transection.

Postoperative course was complicated by an exter-

nal biliary fistula and by a subphrenic abscess.

Eight years after operation, the patient is alive

and well.



1 8 W o r l d J . S u r g . V o l . 6 , N o . 1 , J a n u a r y 1 98 2

lFig. 12. Plurisegmentecto-mies. A. Bisegmentec-tomy VI-VII. B. Biseg-mentectomy IV-V. C. Bi-

segmentectomy V-VI. D.TrisegmentectomyIV-V-VI.

P l u r i s e g m e n t e c t o m i e s

Right Lateral Sectoriectomy, Right Posterior

Sectoriectomy or Bisegmentectomy V1-VII

The line of transection for this liver resection is the

right portal scissura (Figs. 12 and 13). The difficulty

of this procedure is in determining the exact loca-

tion of the right portal scissura, because there is no

visible demarcation between the right lateral and

the right paramedian sectors of the liver. If the right

portal scissura is not properly determined, the

danger is in potential damage to the right hepatic

vein. According to Ton That Tung [4], this scissura

goes parallel to the right side of the liver about 3

fingers' breadths from it, on a plane inclined 40-45 ~

from the horizontal plane. The posterior limit of the

scissura is the right side of the vena cava.

The anterior limit of the right scissura is the

middle of the distance between the gallbladder andthe right angle of the liver.

During the right lateral sectoriectomy, the only

important pedicle to locate is the right lateral portal

pedicle, which is posterior to the level of the hilus.

Through a long right subcostal incision, the right

liver is mobilized from its posterior attachmen ts up

to the vena cava. The capsule of Glisson is divided

from the middle of the distance between the gall-

bladder and the right angle of the liver, anteriorly.

At the anterior surface, the incision follows the

superior lip of the right coronary ligament, 2 cm

from it. At the inferior part of the liver, the incision

of the capsule of Glisson goes from the anterior side

of the liver to the right end of the hilar transverse

fissure. Then, the liver is transected up to the large

posterior and lateral portal pedicle which is divided.

Posteriorly, the right branches of the right hepatic

vein are ligated and divided and the transection of

the liver is continued up to the right side of the vena

cava. During this transection, the right hepatic vein

remains to the left and is not exposed. We have

performed this operation 3 times. However, in 2

patients it was not exact ly a bisegmente ctomy "r6g-

16e." These 2 patients had sustained liver trauma

which involved the posterior part of the right liver.

The transection followed the right lateral scissura

but also, in some places, the line of parenchyma-

tous rupture.

Case Reports. Patient no. 10, a 22-year-old male,

was operated on for intraperitoneal bleeding follow-

ing a traffic accident. The source of bleeding was

the liver. Hemostasis was obtained by ligation ofthe proper hepatic artery. The patient was reoperat-

ed on for posttraumatic liver necrosis. At reopera-

tion, the rupture of the liver followed partially the

right scissura and there was a necrosis of the right

lateral sector. Segments VI and VII were resected.

The postoperative course was marke d by a minimal

external biliary fistula.

Patient no. 11 was a 37-year-old male admitted

with right upper quadrant pain. Scanner and echog-

raphy detected a retrohepatic mass. Angiography

revealed an hypervascular ized lesion located in the

right lateral sector of the liver and in the right



H. B i sm uth e t a l . : Se gm e nte c tom i e s i n L i ve r Sur ge r y 19

Fig. 13. Right la teral sectoriectomy: BisegrnentectomyV I - V I I .

a d r e n a l g l a n d . A t o p e r a t i o n , a l a rg e m a l i g n a n t t u -

m o r (1 0 c m • 1 0 c m ) o f th e r i g h t a d r e n a l g l a n d w a s

f o u n d w h i c h i n v a d e d t h e r i g h t l at e r al s e c t o r o f t h e

l iv e r . T o e x c i s e t h e t u m o r , a r i g h t l a t e r a l s e c t o r i e c -

t o m y w a s p e r f o r m e d e n b l o c w i t h t h e r e s e c t io n o f

t h e r ig h t a d r e n a l g la n d a n d k i d n e y . T w o y e a r s l a t e r,

t h e p a t i e n t is w e l l w i t h o u t t u m o r r e c u r r e n c e .

P a t i e n t n o . 1 2 , a 1 5 - y e a r - o l d g i r l, w a s a d m i t t e d

f o l l o w i n g a tr a f fi c a c c i d e n t , l n t r a p e r i t o n e a l b l e e d i n g

l e d t o a l a p a r o t o m y a t w h i c h a p o s t e r io r r u p t u r e o f

t h e ri g h t l iv e r w a s f o u n d . H e m o s t a s i s w a s o b t a i n e d

b y g a u z e c o m p r e s s i o n . T h e p a t i e n t w a s t r a n s f e r r e d

t o o u r d e p a r t m e n t w h e r e a n g i o g r a p h y r e v e a l e d a n

a r t e r i o p o r t a l f i s tu l a b e t w e e n t h e r i g h t l a t e r a l a r t e r ya n d a p o r t a l b r a n c h . A t o p e r a t i o n , a r i g h t l a t e r a l

s e c t o r i e c t o m y w a s p e r f o r m e d c o m p l e t i n g th e l i v er

r u p t u r e . T h e p o s t o p e r a t i v e c o u r s e w a s u n r e m a r k -

a b l e . F o u r y e a r s a f t e r o p e r a t i o n , t h e p a t i e n t h a s a

n o r m a l l i f e .

Bisegmentectomy IV-V

T h i s o p e r a t i o n ( F i g . 1 4 ) h a s a n e l e c t i v e i n d i c a t i o n ,

w h i c h i s c a n c e r o f t h e g a l l b l a d d e r . I n d e e d , t h e

g a l l b l a d d e r is l o c a t e d a t t h e l e v e l o f t h e m a i n

s c i s s u r a o f th e l i v e r a n d a t y p i c a l r e s e c t i o n o f t h e

Fig. 14. Bisegrnen tectorny IV-V . T he different s teps ofthe technique: (1) Opening of the umbil ical f issure; (2)spl i t t ing of the parenchyma to the r ight of teres l igamen-turn; (3) opening of the r ight portal scissura; and (4)l iga tion of the por ta l pedic les of the qu adra te lobe and ofthe an te r ior por t a l pedic le of the r ight pa ram edian sec tor .

c o n t i g u o u s h e p a t i c p a r e n c h y m a r e q u i r e s t h e r e s e c -

t io n o f s e g m e n t s I V a n d V . A n e x t e n d e d r i g h t

h e p a t e c t o m y - - w h i c h i s n e c e s s a r y w h e n t h e t u m o r

o c c u p i e s a la r g e p a r t o f t h e r i g h t l i v e r - - i s , i n o u r

o p i n i o n [7 ], d i s p r o p o r t i o n a t e w h e n t h e c a n c e r r e -

m a i n s c o n f i n e d to t h e g a l l b l a d d e r b e d o r w h e n i t is

d i s c o v e r e d h i s to l o g i c a ll y f o ll o w i n g c h o l e c y s t e c t o -

m y f o r g a l l s to n e s .T h e m a i n te c h n i ca l s t ep i n b i s e g m e n t e c t o m y I V -

V i s t h e l i g a t io n o f t h e p o r t a l p e d i c l e o f s e g m e n t s I V

a n d V . T h e l ig a t io n m u s t b e d o n e w i t h o u t i m p a i r i n g

t h e v a s c u l a r i z a t i o n o f t h e r i g h t li v e r a n d o f t h e l e f t

l o b e . T h e o p e r a t i o n i s p e r f o r m e d t h r o u g h a r i g h t

s u b c o s t a l i n c i s i o n . T h e t e r e s l i g a m e n t u m a n d t h e

f a l c i f o r m l i g a m e n t a r e d i v i d e d . T h e f i rs t s te p o f t h e

r e s e c t i o n i s t h e l i g a t io n o f th e p o r t a l p e d i c l e s o f

s e g m e n t I V o n t h e r i g h t p a r t o f t e re s l i g a m e n t u m , a s

d e s cr i be d f o r s e g m e n t e c t o m y I V .

T h e s e c o n d s t e p i s t h e l e ft p a r e n c h y m a t o u s t r a n -

s e c t i o n w h i c h i s c o n d u c t e d a l o n g t h e u m b i l i c a l



2 0 W o r l d J . S u r g . V o l . 6 , N o . 1 , January 1982

fissure. The third step is the right liver transection,

which is conducted following a line parallel to the

right lateral scis sura 2 cm on its right. At the inferior

part of the liver, this tran section is directed toward

the right portal pedicle. During this transection, the

large inferior and posterior right paramedian portal

pedicle is found and its anterior branch is ligated.The fourth step is the ligation of the portal branches

on the posterior part of the quadrate lobe. The fifth

step is the posterior parenchymatous transection

which joins the left and right transections in front of

the hilus. During this transverse transection, the

large middle hepatic vein is ligated and divided.

Cas e Repor t s . Patient no. 13, a 42-year-old male,

was admitted with right upper quadrant pain. A1-

pha-fetoprotein levels were elevated and angiogra-

phy revealed a small hypervascular lesion (5 cm in

diameter) in segment IV. At operation, a small,

well-circumscribed hepatocarcinoma was located insegment IV, close to segment V. T he left lobe of the

liver was small. Segments IV and V were resected.

The postoperative course was unremarkable and

the patient is alive and well 2 years after operation.

Patient no. 14 was a 39-year-old female operated

on for gallstones. Histological examination of the

gallbladder revealed a carcinoma of the gallbladder

invading the adventitia. The patient was reop erated

on at our hospital and a resection of segments IV

and V was performed. Histological examination of

these 2 segments revealed no sign of malignancy.

Two years after operation, the patient is alive and

well. Biological and morphologic examinations of

the liver are normal.

Patient no. 15, a 57-year-old male, was operated

on for gallstones. Intraoperatively, a carcinoma of

the gallbladder, which extend ed beyond the serosa,

was discovered. This patient was treated by chole-

cystect omy and then transferred to our department.

Angiography revealed some irregularities of the

branches of the right hepatic artery. The patient

was reoperated on and a segmentectomy IV-V was

performed. Histologically, there was some residual

tumoral tissue in the gallbladder bed. The postoper-

ative course was uncomplicated. Two years afteroperation, the patient died with a tumor recurrenceinvading the duodenum .

Patient no. 16, a 29-year-old female, was operat-

ed on for right upper qu adrant pain associated with

an absence of opacification of the gallbladder. At

operation, a carc inoma of the gallbladder, invading

the gallbladder bed, was found and a chol ecystecto-

my was performed. Postoperatively, the patient

was transferred to our departmen t. The patient was

reoperated on and a bisegmentectom y IV-V was

performed. Histology revealed a tumoral extension

limited to the gallbladder bed. The postoperative

course was uncomplicated and the patient is alive

and well after 2 years. Recently, a second-look

operation was performed which did not disclose any

tumoral recurrence.

Patient no. 17, a 60-year-old female, unde rwen t a

cholecystectomy for gallstones. Histology of the

gallbladder revealed a carcinoma confined to thegallbladder. For this reason, the patient was trans-

ferred to our department. Angiography of the liver

was normal. The patient was reoperated on and a

bisegmentectomy IV-V was performed. Histology

revealed no sign of tumoral extension in the 2

resected segments. The postoperative course was

uncomplicated and the patient is alive and well 2

years after operation.


to our department for right upper quadrant pain.

Liver scintiscan revealed a defect in the right liver.

Angiography showed an hypervascular lesion locat-

ed at the level of the gallbladder bed. At operation,the mass was removed by performing a bisegmen-

tectomy IV-V. Histology revealed a small carcino-

ma of the gallbladder penetrating into the liver. The

postoperative course was uncomplicated and the

patient is alive and well 10 months after operation,

with no sign of tumor recurrence.

B i s e g m e n t e c t o m y V - V I

Proposed by Mancuso et al. [8], this bisegmentec-tomy is rarely performed (Fig. 15).

Just as in resection of the quadrate lobe, a

cholecyst ectomy is performed and the liver is tran-

sected along the main scissura. Contrary to what is

done during the resection of the quadr ate lobe, the

incision of the capsule of Glisson should be slightly

displaced to the right of the main scissura to avoid

the middle hepatic vein during the transection. The

transection is conducted up to the level of the hilus,

and then the liver is transected transversely toward

its right lateral side. This transection is no different

from that described for bisegmente ctomy IV-V and

for segment ectomy VI.

Cas e Repor t s . Patient no. 19 was a 2-year-oldfemale admitted to our department with hepatomeg-

aly. Angiography revealed a huge hypervascular

tumor of the right liver. The lesion, which was a

capsulated hamartoma, was resected by performing

a bisegmentectomy V-VI. The postoperative course

was uneventful and the patient is alive and well 4years later.

Patient no. 20, a 58-year-old male, was admittedfor right upper quadrant pain and hepatomegaly.

Angiography revealed an hypervascularized lesion

located inside the right part of the liver. At opera-

tion, the liver was cirrhotic and the tumor proved to




F i g . 1 5 . B i s e g m e n t e c t o m y V - V I .

J .

U lii! Iii" " ' ,

be an hepatocarcinoma developed on the anterior

edge of the right liver. This hepatocarcinoma was

resected by performing a bisegmentectomy V-VI.

The postoperative course was uncomplicated and

the patient is alive and receiving chemo therap y with

no sign of recurrence 6 months postoperatively.

T r i s e g m e n t e c t o m y I V - V - V I

Described by Ton That Tung [4] as an extended

medial hepatectom y, the resection o f segments IV,

V, and VI was proposed by Couinaud [1] for

treatment of carcinoma of the gallbladder because

the cystic veins are likely to end in the portal b ranchof segment VI (Fig. 16). The first step of this

trisegmentectomy is the same as for the resection of

the quadrate lobe: division of the portal pedicles of

segment IV on the right part o f the umbilical fissure.

Then, the liver is transected along the umbilical

fissure up to the level of the hilus. Afterward, the

capsule of Glisson is incised transversely toward

the right side of the liver and, from this side, a long

transverse transection is performed which leads to

division of the portal pedicles of segments V and

VI, of the origin of the right hepatic vein and of that

of the middle hepatic vein.

Cas e Repor t s . Patient no. 21, a 29-year-old female

on oral contraception for 8 years, was admitted to

our department with a huge mass located in the

right upper quadrant. Angiography revealed an hy-

pervascular lesion occupying segments IV, V, and

VI and vascularized by the right and left hepatic

arteries. Frozen section at operation proved the

tumor to be an adenoma. The left lobe of the liver

was atrophied. Because of the risk of an extended

right hepate ctomy for a benign tumor , an intraopex'-

ative embolization of the right branch of the hepatic

artery was performed to reduce the size of the

tumor. A few months later, the mass had shrunk.

The patient was reoperated on and a trisegmentec-

tomy IV, V, VI was performed. The postoperativecourse was uneventful and the patient is alive and

well 2 years after operation.Patient no. 22 (Fig. 17) was a 65-year-old man

admitted to our department with hepatomegaly.

Alpha-fetoprotein levels were markedly increased

and angiography revealed an hypervascularized

mass occupying segments IV, V, and VI. Because

of the presence of neoplastic lymph nodes in the

porta hepatis, a palliative resection of segments IV,

V, and VI was performed. This resection required

no transfusion and the postoperative course was

uncomplicated. A treatment regimen of chemo-



2 2 W o r l d J . S u r g . V o l . 6 , N o . 1 , J a n u a r y 1 9 82

Fig. 16. Trisegmentectomy IV-V-VI.

therapy and immunotherapy was started. Nine

months after operation, echography revealed a re-

current tumor in the liver. At reoperation, there

were diffuse neoplastic nodules in the left lobe and

in the remaining right liver. A ligation of the hepatic

artery was performed. The patient is still alive and

well 2 years after the first operation.

Discuss ion

Right and left hepatectomies and right and left

lobectomies are the 4 most commonly performed

liver resections. Segmental resections of the liver

are rarely performed. Apart from Ton That Tung

[4], who has the largest experience with this type of

liver resection, only a few cases have been pub-

lished.

From almost 100 liver resections performed in

our experience, we report herein 22 cases of seg-

mental liver resections. Intra- and postoperative

mortality was nil. In 4 patients, minor po stoperative

complications occurred which did not require reop-

eration. In a patient with cirrhosis, postoperative

hepatic insufficiency was observed following seg-

mentectomy VI.

Segmental resections of the liver are based upon

a precise knowledge of the anatomical organization

of the liver and especially of the distribution of the

portal pedicles and hepatic veins which allowed

Couinaud [1] to individualize 8 functional units in

the liver: the segments are also called "subseg-

merits" by Ton That Tung [4] and by Goldsmith and

Woodburne [2].

From the technical point of view, segmental liver

resections require a primary transparenchymatous

approach as advocated by Ton That Tung [4]. For

most of them, the resection is easy to perform and,

providing that the anatomical rules are respected,

no more difficult than the usual hepatectomies.

Right posterolateral sectoriectomy and complete

segmentectomy IV are more difficult to perform

because of the difficulty in finding the line of

cleavage for the former and to the 3 large planes ofparenchymatous transection required by the latter.

The main justification for choosing, in some

cases, a segmental liver resection rather than one of

the 4 common hepatectomies is the lesser amount of

normal parenchyma excised, thus minimizing the

degree of postoperative hepatic insufficiency.

The minimal amount of functional liver to sustain

life is still ill-defined. We believe that the risk of

fatal postoperative liver failure following fiver re-

section is greatest when the remaining functional

liver is small or cirrhotic.

The risk of postoperative hepatic failure follow-

ing a right extended hepatectomy is a subject ofmuch discussion. Starzl [9] had only 1 case o f fatal

postopera tive hepatic insufficiency in his series of

30 right extended hepatectomies but, in this case,

there was a necrosis of the remaining left lobe due

to vascular thrombosis. In another case, a severe

postoperative hepatic insufficiency with ascites was

observed [10]. Beattie [I 1] reported 1 case of post-

operative hepatic failure and st ated tha t the left lobe

only is insufficient to support life. In our series of 12

right extended hepatectomies 1 patient, whose left

lobe was smaller than normal, had such a dramatic

course. In explaining these differences, the volume

of the remaining liver is, in our opinion, the deter-

mining factor. Usually, tumors of the right liver,

which are the indications for an extended right

hepatectomy, are large tumors which destroy a

large part o f the right lobe. A conc omitant hypertro-

phy of the left lobe is usually present. In some

cases, however, the left lobe retains its normal size,

that is to say, 10-15% of the liver [12] or is smaller

because o f constitutional atrophy. We think that, in

this latter event, a right extended hepatectomy

carries a risk of fatal postoperative hepatic failure;

the frequency is, however, difficult to state.




Fig. 17. Patient no. 22. A. Excision of an hepato carc inom a at the anter ior edge of the right lobe by a trisegm entec tomy IV -V-V I. B. View of the specimen.

T h e s eco n d c i r cu m s t an ce i n w h i ch a cau t i o u s

a t t i tu d e co n c e rn i n g t h e r e s ec t i o n o f t h e fu n c t i o n a l

p a r en ch y m a i s ad v i s ab l e i s m e t i n c i r rh o t i c p a t i en t s .

T h e r i s k o f p o s t o p e ra t i v e h ep a t i c f a i l u r e i s p a r t i cu -

l a r l y h i g h w h en c i r rh o s i s i s s ev e re (B o r C g rad e ,

acco rd i n g t o Ch i l d ' s c l a s s i f i ca t i o n ) o r w h en a l a rg e

a m o u n t o f c ir r h o ti c p a r e n c h y m a h a s t o b e r e m o v e d

w i t h t h e t u m o r . I n o u r s e r i e s o f l i v e r r e s ec t i o n s i nc i r rh o t i c p a t i en t s , a r i g h t h ep a t ec t o m y w as p e r -

f o r m e d f o r a t u m o r d e v e l o p e d a t t h e a n t e r i o r e d g e

o f th e r i g h t l iv e r . B ecau s e o f t h e s u p e r f i c ia l l o ca t i o n

o f t h e t u m o r , t h i s r e s ec t i o n r em o v e d a la rg e am o u n t

o f n o n t u m o r a l c i r r h o ti c p a r e n c h y m a . T h e p a t i e n t

d i ed a l t e r 1 0 d ay s f ro m p ro g r es s i v e h ep a t i c f a i l u r e .

T h es e 2 r e s t r i c t i o n s t o m a j o r h ep a t ec t o m i es a r e ,

i n o u r o p i n i o n , a m o t i v a t i o n t o ch o o s e - - i n s o m e

cas es - - a l e s s ex t en s i v e s u rg e ry , t h a t i s t o s ay , a

s eg m en t a l r e s ec t i o n .

Wh en t h e b en i g n n a t u re o f a s ol i d li v e r t u m o r i s

a f f irm ed i n t r ao p e ra t i v e l y b y f ro ze n s ec t i o n , t h e re i s

n o r e a s o n f o r a n e x t e n s i v e r e s e c t i o n o f t h e n o r m a l

s u r r ou n d i n g p a r e n c h y m a . I f se g m e n t a l r e s e c t i o n

w o u l d ap p ea r ea s i l y an d s a f e l y p e r fo rm ed i n t h e

g i v en cas e , i t i s r ea s o n ab l e t o ch o o s e t h i s t y p e o f

r e s e c t i o n r a t h e r t h a n a l a r g e r c o m m o n h e p a t e c -

t o m y . A s r eg a rd s t r au m a o f t h e l i ve r , t h e f r eq u en t

l o ca t i o n o f t h e ru p t u r e a t t h e p o s t e r i o r p a r t o f t h e

r i g h t l i v e r i s a g o o d i n d i ca t i o n fo r a p o s t e ro l a t e r a lr i g h t s ec t o r i ec t o m y s u ch a s w e d i d i n 2 ca s es . A

p a r t i cu l a r i n d i ca t i o n fo r t h e r e s e c t i o n o f t h e q u ad -

ra te lobe can be m et in the f ie ld o f b i li ary surg ery : to

g a i n acces s t o t h e u p p e r p a r t o f th e b i l i a ry co n f lu -

en ce [6 ] o r t o p e r fo rm an i n t r ah ep a t i c ch o l an g i o en -

ter ic ana s tom os is [13] .

Seg m en t a l r e s ec t i o n s i n m a l i g n an t t u m o rs a r e

i n d i ca t ed i n s o m e p a r t i cu l a r co n d i t i o n s . I n a s e r i e s

o f 38 p a ti e n ts w h o u n d e r w e n t l i v er r e s e c t i o n f o r

h e p a t o c a r c i n o m a s , w e p e r f o r m e d 5 s e g m e n t a l r e -

s ec t i o n s . I n 2 ca s es , t h e p ro ced u re w as p e r fo rm ed

b ecau s e o f a s s o c i a t ed c i r rh o s i s , i n 2 o t h e r ca s es ,



2 4 W o r l d J . S u r g . V o l . 6 , N o . 1 , J a n u a r y 1 9 8 2

t h e h e p a t o c a r c i n o m a w a s s m a l l a n d l o c a t e d i n t h e

q u a d r a t e l o b e , e q u i d i s t a n t f r o m t h e m a i n s c i s s u r a

a n d t h e u m b i l i c a l f i s s u r e . F r o m t h e c a r c i n o l o g i c a l

p o i n t o f v ie w , a r i gh t e x t e n d e d h e p a t e c t o m y o r a

l ef t h e p a t e c t o m y h a s n o a d v a n t a g e w h e n c o m p a r e d

t o a s e g m e n t e c t o m y I V w h i c h f o l l o w s t h e s a m e

s c i s s u r a e . I n t h e l a s t c a s e , t h e r e s e c t i o n w a s p a l l ia -

t i v e .

A n o t h e r i n d i c a t i o n f o r s e g m e n t a l l i v e r r e s e c t io n

is c a r c i n o m a o f th e g a l l b l a d d e r w h e n m a l i g n a n c y i s

d i s c o v e r e d b y h i s t o l o g i c a l e x a m i n a t i o n o f a ga l l-

b l a d d e r s p e c i m e n r e m o v e d f o r g a l l s to n e s . I f h i st o l o-

g y r ev e a l s t h at t h e c a r c i n o m a h a s e x t e n d e d b e y o n d

t h e w a l l o f t h e g a l l b l a d d e r , w e t h i n k t h a t t h e r e i s a n

i n d i ca t io n f o r a c o m p l e m e n t a r y l i v er r e s e c t io n . T h i s

r e s e c t i o n s h o u l d r e m o v e t h e c o n t i g u o u s l i v e r p a r e n -

c h y m a : s e g m e n t s I V a n d V . T h e r i g h t e x t e n d e d

h e p a t e c t o m y , w h i c h i s o f t e n p r o p o s e d , is in o u r

o p i n i o n d i s p r o p o r t i o n a t e [7 ] s i n c e i t r e m o v e s a n

a l m o s t e n t i r e l y n o r m a l r i g h t l o b e . T h r e e o f o u rp a t i e n t s o p e r a t e d o n b y a b i s e g m e n t e c t o m y I V - V

a f t e r h i s to l o g ic a l d i s c o v e r y o f a c a r c i n o m a o f t h e

g a l l b l a d d e r a r e p r e s e n t l y a l i v e a f t e r m o r e t h a n 2

y e a r s w i t h n o s ig n o f t u m o r r e c u r r e n c e .

I n c o n c l u s io n , m a j o r a n d m i n o r h e p a t i c s e g m e n -

t e c t o m i e s " r d g l d e s " a r e o n e o f t h e b e s t i ll u s t r a ti o n s

o f th e a n a t o m i c a l s u r g e r y o f t h e l iv e r . T h e y a r e n o t

t e c h n i q u e s " d e f a c i l i t6 " w h i c h c a n b e c h o s e n f o r a

r a p i d a n d e x p e d i t i o u s s u r g e r y . T h e y a r e i n t e r e s t i n g

a l t e r n a t i v e s t o t h e c o m m o n h e p a t e c t o m i e s w h e n a

m o r e e c o n o m i c a l r e s e c t i o n i s p e r m i t t e d b y t h e

l o c a ti o n a n d t h e n a t u r e o f th e l e s i o n , o r w h e n a

m a j o r h e p a t e c t o m y i s l ik e l y to e x p o s e t h e p a t i en t t ot h e r is k o f p o s t o p e r a t i v e h e p a t i c f a i l u r e .

R~sum~

L ' i n d i v id u a l i s a t io n d u s e g m e n t c o m m e u n i t6 a n a t o -

m i q u e f o n c t i o n n e l l e h 6 p a t i q u e p e r m e t l a r 6 a l is a t io n

d e s e g m e n t e c t o m i e s . E l l e s s o n t r d g l d e s p a r c e q u e

l e s p l a n s d e s e c t i o n d u p a r e n c h y m e h ~ p a t i q u e s u i -

v e n t d es s c i s s u r es a n a t o m i q u e s . D u p o i n t d e v u e

t e c h n i q u e , l e s s e g m e n t e c t o m i e s h 6 p a t i q u e s s e c a r -

a c t d r is e n t p a r u n a b o r d t r a n s p a r e n c h y m a t e u x e x -c l u s i f d e s p d d i c u l e s v a s c u l a i r e s . N o u s a v o n s r d a l is 6

c e t y p e d ' i n t e r v e n t i o n c h e z 2 2 m a l a d e s s a n s m o r t a l -

i t 6 . L e s i n d i c a t i o n s p r i n c i p a l e s s o n t : ( 1 ) q u e l q u e s

t u m e u r s b d n i g n e s , ( 2) c e r t a i n s t r a u m a t i s m e s d u

f o i e , ( 3 ) l a c h i r u r g i e b i l i a i r e s u s - h i l a i r e o i l u n e

r d s e c t i o n d e l a p a r t i e a n t 6 r i e u r e d u s e g m e n t I V p e u t

~ t r e n d c e s s a i r e , e t ( 4 ) l e c a n c e r v d s i c u l a i r e l o r s q u ' i l

a ~t~ d d c o u v e r t s u r u n e p i 6 c e d e c h o l e c y s t e c t o m i e .

L e s s e g m e n t e c t o m i e s h 6 p a t i q u e s p e u v e n t f i tr e i nd i-

q u 6 e s 6 g a l e m e n t d a n s c e r t a i n e s t u m e u r s m a l i g n e s

l o r s q u e le f o ie e s t c i r r h o t i q u e o u l o r s q u ' u n e e x 6 r 6 s e

6 1 ar gi e f a i t c o u r i r u n r i s q u e d ' i n s u f f i s a n c e h 6 p a -

t iq u e . L ' u n d e s a v a n t a g e s p r i n c i p a u x d e s r d s e c t i o n s

s e g m e n t a i r e s d u f o i e e s t e n e f f e t d e p e r m e t t r e u n e

e x d r ~ s e 6 c o n o m i q u e d u p a r e n c h y m e h d p a t i q u e .

References

1 . Cou inaud , C . : Le Fo ie . E tudes A na tomiques e t Ch i r-urgica les. Par is , Masson, 1957

2 . Go ldsmi th , N .A. , Woodburne , R .T . : The su rg i ca lana tom y pe r t a in ing t o l i ve r r e sec t i on . Surg . G yneco l .Obste t . 195:310, 1957

3 . Hea l ey , J .E . , Schroy , P .C . : Ana to my o f t he b il i aryducts wi thin the human l iver . Arch. Surg. 66:599,1953

4 . Ton Tha t Tung : Les Rdsec t i ons Ma jeure s e t Min-eures du Foie . Par is , Masson, 1979

5. Caprio , G. : Un caso de ext i rpacion del Iobulo iz -quierdo del higado. Bul l . Soc . Cir . Urug. Montevideo2:159, 1931

6. Cham peau, M ., Pineau, P. : V oie d 'abord 61argiet rans-hdpat ique du canal hdpat ique gauche. Mere .Acad. Chir. 90:602, 1964

7. Bism uth, H. , Mal t , R. : Carc in om a of the bi lia ry t rac t .N. Engl . J . Med. 301:704, 1979

8 . Mancu so , M. , Na ta l i n i, E . , De l Grande , G. : Con t r i b -uto a l la conoscenza del la s t rut tura segmentar ia de lfegato in rapporto a l problema del la resez ione epat i -ca. Policlinico. Sez. Chir. 72:1955

9. Starz l , T .E . , K oep , L .J . , Wei ll , R. , I I I , Li l ly , J .R. ,Pu tnam, C .W. , Ald re t e , J .A . : R igh t t r i segmentec -tomy fo r hepa t ic neop la sms . Surg . Gyn eco l . Obs t e t .150:208, 1980

10 . S t a rz l , T .E . , Pu tnam, C .W. , Gro th , C .G. , Corman ,J .L . , Taubm an , J . : Alopec i a , a sc it e s , and i ncomple t eregene ra t i on a f t e r 85 t o 90 pe r cen t l i ve r r e sec t i on .Am. J . Surg. 129:587, 1975

11. Beat t ie , E .G. : Discussion in McBride , C.M., Wal-lace , C. : C ance r of the r ight lobe o f the l iver . Ava r i e ty o f ope ra t i ve p rocedure s . A rch . Surg . 105:289,

1972

12. S tone , H.H . , Lo ng , W.D. , S mi th , R .B . , Hayn es ,C .D. : Phys io log i ca l cons ide ra t i ons i n m a jo r hepa t icre sec t i ons . Am. J . Surg . 117:78, 1969

13. Bismuth, H. , Corle t te , M.B.: Int ra-hepat ic cholan-g io -en t er i c anas tomos i s i n ca rc inom a o f t he h il us o fthe l iver . Surg. Gynecol . Obste t . 140:170, 1975

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