ARTICLE IN PRESS

Surgical Oncology (]]]]) ], ]]]]]]

Available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/suronc

REVIEW

Central hepatectomy: The golden mean for treating

central liver tumors?
Charalabos Stratopoulos, Zahir Soonawalla, Jens Brockmann,
Kathrin Hoffmann, Peter J. Friend
Nufeld Department of Surgery, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
Accepted 7 May 2007

KEYWORDS
Central hepatectomy;
Mesohepatectomy;
Liver tumors

Abstract
The treatment of patients with central liver tumors involving segments 4, 5 and 8 is a
difcult clinical problem. These tumors often straddle Cantlies line and involve parts of
both lobes of the liver. The traditional management of such tumors is to perform either an
extended right or an extended left hepatectomy. However, extended hepatectomies are
associated with greater morbidity and mortality, mainly due to increased risk of
postoperative liver failure. Central hepatectomy (or mesohepatectomy) may be superior
to extended hepatectomy, because it conserves more liver parenchyma. However, the
operation can be tedious and may result in increased blood loss, and was therefore
infrequently used. Recommendations for its application for centrally located tumors are
not clear. The aim of our study is to evaluate the evidence supporting central hepatectomy
as a safe procedure for the management of central hepatic tumors, and to describe the
effectiveness of central hepatectomy compared to extended hepatectomy. We present
herein two patients who underwent central hepatectomy and systematically review the
English literature until December 2006.
We found 13 studies of multisegmental (X2 segments) central liver resection that included
at least four patients. Only three retrospective non-randomized studies have looked at
central hepatectomy in comparison to lobar or extended hepatectomy, and no clear
consensus emerges. To date, there is insufcient evidence to categorically state that
central hepatectomy is superior to extended hepatectomy, thus the use of all approaches
can be justied. However, if central hepatectomy can be performed without excessive
blood loss, then it should be preferred, as it is less extensive and results in greater

Corresponding author. 7 Diomidous Road, 15238 Chalandri, Athens, Greece. Tel.: +30 2106083533; fax: +30 2106108753.

E-mail addresses: harstrat@otenet.gr (C. Stratopoulos), soonawalla@aol.com (Z. Soonawalla), jens.brockmann@ukmuenster.de

(J. Brockmann), katrin.hoffmann@med.uni-heidelberg.de (K. Hoffmann), peter.friend@nds.ox.ac.uk (P.J. Friend).
0960-7404/$ - see front matter & 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.suronc.2007.05.002
Please cite this article as: Stratopoulos C, et al. Central hepatectomy: The golden mean for treating central liver tumors? Surg Oncol
(2007), doi:10.1016/j.suronc.2007.05.002

ARTICLE IN PRESS
2

C. Stratopoulos et al.
functional remnant liver. Additionally, it would clearly be superior in patients with
cirrhosis.
& 2007 Elsevier Ltd. All rights reserved.

Contents
Case reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Case 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Case 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Review of the literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Searching methodology and study selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anatomic basis and rationale for central hepatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Patient selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Studies of multisegmental central liver resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mortality and morbidity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Impact of different techniques of vascular occlusion on operative blood loss . . . . . . . . . . . . . . . . . . . . .
Comparison of central hepatectomy with lobar or extended hepatectomy. . . . . . . . . . . . . . . . . . . . . . .
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Case reports
From March 2003 to July 2004, 50 consecutive patients with
liver tumors were referred to our center for elective liver
resection. During this period, two patients underwent
central hepatectomy for central liver tumors. Our standard
surgical approach is through a bilateral subcostal incision
with midline extension. After mobilizing the liver, our usual
practice is extrahepatic division of hepatic arterial and
portal venous inow, followed by extrahepatic division of
the relevant hepatic veins. The patient is then positioned
with a 5151 head-up tilt, aiming to lower the central venous
pressure (CVP) to 5 mmHg or less, while maintaining
adequate blood pressure. Parenchymal transection is performed with the Cavitron ultrasonic surgical aspirator CUSA
(Valleylab, Boulder, CO, USA) and Ultracision harmonic
scalpel (Ethicon Endo-surgery Inc., Cincinnati, OH, USA).
Hemostasis is achieved by argon beam coagulation. We did
not perform a Pringle maneuvre in either of these cases.

Case 1
A 61-year-old male was referred for surgical resection of a
solitary hepatic metastasis. He had undergone a high
anterior resection for a Dukes B (T3, N0, R0) sigmoid
adenocarcinoma 3 months previously. Magnetic resonance
imaging (MRI) disclosed a 2.6 cm lesion consistent with a
metastasis in segment 4b of the liver (Fig. 1). The patient
was advised surgical resection of this presumed solitary
metastasis, rather than rst undergoing neoadjuvant chemotherapy. At surgery, a 2.8 cm tumor was found close to
the gallbladder involving segments 4b and 5, while two
smaller lesions were found in segment 8 of the liver.
Intraoperative ultrasound of the liver conrmed the above
ndings of open inspection and palpation. A mesohepatectomy was performed (Fig. 2) including most of segments 4b, 5
and 8. The middle hepatic vein was divided intrahepatically

2
2
2
3
3
3
3
4
4
4
5
5
5
7
7

with a vascular stapler. Surgical time was 210 min, while

blood loss was 900 ml. The patient did not need any blood
products and was discharged on the sixth postoperative day
after an uneventful recovery. Histology conrmed three
hepatic metastases from colorectal adenocarcinoma, with
clear resection margins.

Case 2
A 71-year-old female was referred to our department for
surgical treatment of a tumor in segment 8 of the liver. She
had undergone a right hemicolectomy 6 months before for a
Dukes B (T3, N0, R0) cecal adenocarcinoma. On MRI, a
3.2 cm lesion within segment 8 of the liver was identied
(Fig. 3). The patient was advised surgical resection, with a
plan to perform a segmental resection. At operation, the
lesion was found to be closer to the middle hepatic vein than
expected, and a central hepatectomy was performed with
excision of segments 5 and 8, along with the middle hepatic
vein, preserving all of segment 4b and part of segment 4a
(Fig. 4). The duration of the operation was 200 min, the
blood loss was 2000 ml and the patient received two units
packed red cells. The patient was discharged on the eighth
postoperative day after an uneventful course. Pathologic
examination revealed a hepatocellular carcinoma (HCC),
positive for Hepar1, alpha1 antitrypsin, focally for cytokeratin (CK) 8 and CK18 and negative for CK7, CK20 and alphafetoprotein. The background liver showed no evidence of
cirrhosis or other underlying liver disease, and postoperative
tests for hepatitis viruses, hemochromatosis and primary
biliary cirrhosis were negative.
In summary, both patients underwent uneventful central
hepatectomy with acceptable blood loss and no postoperative liver failure. All tumors were removed with
grossly negative margins. At a follow-up of 33 and 28
months, respectively, the patients are doing well with no
signs of recurrence.

Please cite this article as: Stratopoulos C, et al. Central hepatectomy: The golden mean for treating central liver tumors? Surg Oncol
(2007), doi:10.1016/j.suronc.2007.05.002

ARTICLE IN PRESS
Central hepatectomy: treating central liver tumors?

Fig. 1 MRI abdomen image in rst patient: the 2.6 cm tumor

(arrow) is located in segment 4b.

Review of the literature

Searching methodology and study selection
The aim of our review was to evaluate the evidence
supporting central hepatectomy as a safe procedure for
the management of central hepatic tumors and to compare
central hepatectomy to extended hepatectomy. A systematic literature search was conducted on medline until
December 2006. Database searches used the keywords
central hepatectomy, central liver resection, mesohepatectomy, right anterior segmentectomy, central bisegmentectomy, central trisegmentectomy, segmental liver
resection and segment oriented liver resection. There were
restrictions regarding the language of publication (only
English language) and the number of reported cases (more
than 3). We used the oxford hierarchy for grading clinical
studies according to the levels of evidence.

Anatomic basis and rationale for central

hepatectomy
Surgery remains the only curative option for either primary
or secondary liver tumors [1,2]. Surgical treatment of
centrally located tumors (Couinauds segments 4a, 4b, 5
and 8) has always been a challenge. Traditionally, extended
right or left hepatectomies have been used for the
extirpation of central liver tumors. However, these methods
remove 6080% of liver parenchyma, and are associated with

Fig. 2 Liver transection plane after mesohepatectomy (Couinauds segments 4a, 4b, 5 and 8). LL indicates left lateral
segments (Couinauds segments 2 and 3); and RP, right posterior
sector (Couinauds segments 6 and 7).

considerable risk of postoperative liver failure [3]. A nonanatomical resection is an alternative approach for parenchymal preservation, but hindered by intraoperative
hemorrhage and higher rates of margin positivity between
19% and 35% [4]. For tumors limited to the left medial and
right anterior sectors, central hepatectomy is an attractive
option because it entirely removes the tumor-bearing
segments while preserving the rest of the liver.
Ipsilateral portal vein embolization can be considered
preoperatively to allow hypertrophy of the contralateral
unaffected liver parenchyma, thereby facilitating extended
resections. However, with centrally located tumors it is
often difcult to determine which side of the portal vein
should be embolized. Moreover, there is minimal evidence
that this procedure affects the resectability rate or
improves survival [5].

Terminology
The terminology that has been used for liver resections of
the central part of the liver is inconsistent. Confusion may
arise due to the use of the terms central hepatectomy [6],
middle lobectomy [7], central bisegmentectomy [8] or

Please cite this article as: Stratopoulos C, et al. Central hepatectomy: The golden mean for treating central liver tumors? Surg Oncol
(2007), doi:10.1016/j.suronc.2007.05.002

ARTICLE IN PRESS
4

C. Stratopoulos et al.

central trisegmentectomy [9]. The scientic committee of

the Hepato-Pancreatico-Biliary Association has created a
rationale and anatomically correct nomenclature for liver
resections [10]. According to that, the resection of segments
5 and 8 is named right anterior sectionectomy, while
resection of segments 4a and 4b is named left medial
sectionectomy. There is no proposed name for the resection

of segments 4a, 4b, 5 and 8. This operation has now

predominantly been termed mesohepatectomy or central
hepatectomy [11].

Patient selection
The selection criteria in the literature for central hepatectomy include non-cirrhotic patients or Child-Pugh class A
or B patients with indocyanine green 15-min retention rate
(ICG R15) less than 20%, removal of all tumors with a 1-cm
margin and preservation of venous drainage as well as
vascular supply to the remaining segments [1113].

Studies of multisegmental central liver resection

Most of the literature regarding central hepatectomy for
liver tumors reports outcome data of a mixed patient
population (cirrhotic and non-cirrhotic, primary and secondary tumors). Individual studies are difcult to compare
because of differences in patient selection. However, a
number of reports are available that demonstrate the
feasibility of central liver resection with an acceptable
mortality and morbidity. Table 1 summarizes several studies
of multisegmental (X2 segments) central liver resection.
Non-randomized studies comparing central hepatectomy
with lobar or extended hepatectomy are presented in
Table 2.

Mortality and morbidity

Fig. 3 MRI abdomen image in second patient: within segment 8

of the liver there was a 3.2 cm lesion (arrow). A simple cyst was
located at segment 6.

The surgical mortality rate has been reported to be between

0% and 6.25%. The most frequent causes of perioperative
death are liver failure and hemorrhage [4,8,9,1120].
Postoperative early morbidity rates are as high as 55%,
due to hemorrhage (5.66.2%) [8,12], bile leakage (5.6
12.5%) [8,9,1113], liver failure (5.86.2%) [8,13], ascites
(1.911.6%) [8,9,1113,19], wound infection (1.76.2%)

Fig. 4 Liver transection plane after resection of right anterior segment with part of the middle hepatic vein (Couinauds segments 5
and 8), preserving all of segment 4b and most of segment 4a. FL indicates falciform ligament; LM, left medial segment (Couinauds
segment 4); LL, left lateral segment (Couinauds segments 2 and 3) RP, right posterior sector (Couinauds segments 6 and 7).
Please cite this article as: Stratopoulos C, et al. Central hepatectomy: The golden mean for treating central liver tumors? Surg Oncol
(2007), doi:10.1016/j.suronc.2007.05.002

ARTICLE IN PRESS
Central hepatectomy: treating central liver tumors?
[8,19], intraabdominal abscess (0.81.9%) [9,19], pneumonia (1.712.5%) [8,12,13,19] and pleural effusion (5.7
23.5%) [8,9,11,13,19,20]. Some reports [16] identied
central hepatectomy as an independent risk factor for bile
leakage because of the presence of two transection planes
and exposure of the hepatic hilum.

Impact of different techniques of vascular occlusion

on operative blood loss
In most cases, total inow occlusion (Pringle maneuvre)
[1113,17,19,20], hemihepatic inow occlusion [4,8,11
13,17], alternate partial hepatic vascular occlusion with
preservation of caval ow [15,18] or total inow occlusion
with occlusion of the inferior vena cava below the liver [19]
was used for controlling bleeding during transection of the
parenchyma. These techniques can reduce the requirements
for intraoperative blood transfusion [8,15]. Two prospective
randomized trials have compared different techniques of
vascular occlusion for central liver resections in patients
with cirrhosis [17,19]. The rst trial showed that operative
blood loss during declamping was signicantly greater in
total inow occlusion group than in hemihepatic inow
occlusion group [17]. The second trial demonstrated that
operative blood loss during liver resection was signicantly
greater in total inow occlusion group than in the group
undergoing total inow occlusion with occlusion of the
inferior vena cava below the liver [19]. There were no
signicant differences in liver enzyme changes or postoperative morbidity and mortality between comparative
groups.
Many centers nowadays perform liver resection without
total inow occlusion, and nd that blood loss during surgery
remains low due to the use of low-CVP anesthesia and
modern techniques to transect liver parenchyma. In the
present study, the Pringle maneuvre was not used in either
of the resections.

Comparison of central hepatectomy with lobar or

extended hepatectomy
The question remains whether central hepatectomy or
extended hepatectomy is the preferred operative approach
for the management of centrally located liver tumors. Three
retrospective studies investigated this question (Table 2)
[9,11,12]. No difference in perioperative morbidity and
mortality, or mean postoperative hospital stay could be
demonstrated in these comparative studies.
Wu et al. [11] found that mesohepatectomy and extended
hepatectomy performed equally well for centrally located
HCCs. Mesohepatectomies required a signicantly longer
inow occlusion time for liver parenchymal transection than
did extended hepatectomies. Patients who underwent
extended hepatectomy had worse 1-, 3- and 6-year
disease-free survival rates, but this was not statistically
signicant and may have been because of different tumor
stages.
In the study conducted by Hu et al. [9], the outcome was
very similar in patients with centrally located HCCs of
comparable size who underwent treatment with central
hepatectomy and conventional major hepatectomy. It was

5
noted that the volume of transfused blood was signicantly
greater in central hepatectomy group than in major
hepatectomy group (1030 ml versus 445 ml).
The third retrospective study has compared the results of
central hepatectomy and lobar or extended hepatectomy
for centrally located primary or secondary liver tumors [12].
The groups had similar patient demographics by age,
background liver disease and indications for resection. It
was demonstrated that mesohepatectomy resulted in a
signicantly lower late morbidity rate than extended
hepatectomy (5.6% versus 14%) In this study, the mean
operative blood loss was lower in the mesohepatectomy
group than in the extended hepatectomy group. The overall
duration of mesohepatectomy was signicantly shorter than
extended resection. The mean volume of resected liver in
the mesohepatectomy group was signicantly smaller
(560 cm3) than in the lobar (900 cm3) and extended
hepatectomy (1500 cm3) groups. Mesohepatectomies required a signicantly longer inow occlusion time for liver
parenchymal transection than did lobar hepatectomies.

Discussion
The treatment of large or deep-seated tumors that are
located at the central part of the liver remains problematic.
In these cases, extensive liver resection or non-anatomic
wedge resection is usually recommended. Extensive liver
resection (extended right or left hepatectomy) bears a
considerable risk of liver failure because of compromised
liver functional reserve, particularly in patients with chronic
liver disease [21]. Postoperative liver failure occurs after
extensive resection, even in non-cirrhotic patients [21,22].
On the other hand, non-anatomic wedge resections are
associated with higher rates of positive resection margin and
shorter survival rates than anatomical resections [23].
Improvements in the understanding of liver structure,
based on functional segmental anatomy, together with
advances in imaging technology have contributed to the
development of segment-orientated liver surgery [4].
Central hepatectomy removes part or all of the left medial
sector (segments 4a and 4b) and part or all of the right
anterior sector (segments 5 and 8). It represents an
alternative option, for those patients with liver cirrhosis
and patients with normal liver function. A surgeon who sees
a patient with a centrally located hepatic tumor must
evaluate whether an extended hepatectomy or a central
hepatectomy should be performed. There is no evidence in
the literature to support either approach or formulate
guidelines for the use of one or the other.
The performance status of the patient must be considered. Routine preoperative assessment of hepatic functional
reserve includes clinical assessment, liver biochemistry,
coagulation prole, platelet count, and Child-Pugh classication. The use of Child-Pugh classication has been used to
select cirrhotic patients for liver resection. The ICG R15 has
been found to be useful in predicting the safe limit of liver
resection and decreasing posthepatectomy liver failure. For
patients undergoing major hepatectomy, computed tomography (CT) volumetry is helpful in evaluating whether the
remnant liver volume is adequate. Patients with less than
25% of normal liver remaining after extended resections

Please cite this article as: Stratopoulos C, et al. Central hepatectomy: The golden mean for treating central liver tumors? Surg Oncol
(2007), doi:10.1016/j.suronc.2007.05.002

17

18
27
37
52
19
117

5, 8c

4, 5, 8d

1, 4, 5, 8e

4, 5, 8
1, 4, 5, 8f

4, 5, 8

4, 5, 8g

4, 5, 8h
4, 5, 8i
4, 5, 8j

4, 5, 8k

5, 8

2b
4

2b

3b

1b
2b
4

1b

HCC, CC, HS

HCC

NA
HCC
NA

HCC, CRM,
GBC
NA

HCC
NA

Hilar CC

HCC, CC, CRM,

GM
NA

HCC, CRM

Indication

2.8

0.8

0
0
0

NA

0
0

NA

NA

5.8

6.25

Operative
mortality
(%)

5.7

30.5

NA
17
NA

NA

55.5

20
NA

NA

NA

41.1

37.5

Total early
complication
rate (%)

NA

NA

NA
51
NA

NA

NA

NA
NA

NA

NA

NA

34

Median
survival
(month)

5.5

2.1

NA
4.4
4.6

NA

3.9

7.9
NA

NA

NA

6.8

NA

Mean
operative
time (h)

NA

592

NA
NA
NA

NA

914

2450
NA

NA

NA

1482

NA

Mean blood
loss (ml)

NA

NA

NA
NA
NA

NA

14.9
NA

NA

NA

NA

NA

Postoperative
hospital stay
(day)

Yes

Yes

Yes
NA
Yes

NA

Yes

Yes
Yes

NA

Yes

Yes

Yes

Vascular
occlusion

LoE, level of evidence; HCC, hepatocellular carcinoma; CRM, colorectal metastases; CC, cholangiocarcinoma; GM, gastric metastasis; GBC, gallbladder carcinoma; HS, hepatic sarcoma
and NA, not assessed.
a
Studies are ordered according to year of publication.
b
Including 1 resection of segments 4, 5, 7 and 8.
c
Including 4 resections of segments 5, 8 plus part of 4 and 1 resection of segments 5, 7 and 8.
d
Including 1 right anterior sectionectomy (segments 5 and 8).
e
Including 6 resections of segments 1 and 4 and 2 resections of segments 1, 5 and 8.
f
Including 1 resection of segments 4 and 5.
g
Including 11 right anterior sectionectomies (segments 5 and 8).
h
Including 9 right anterior sectionectomies (segments 5 and 8); 6 resections of segments 4 and 5; 3 resections of segments 5, 7 and 8 and 2 resections of segments 4a and 8.
i
Including 16 right anterior sectionectomies (segments 5 and 8).
j
Including 2 resections of segments 4b and 5 and 1 resection of segments 4a and 8.
k
Including 15 right anterior sectionectomies (segments 5 and 8).

35

15
4

15

16

4, 5, 8b

No. of
patients

Hasegawa et al.
(1989) [8]
Makuuchi et al.
(1993) [13]
Billingsley et al.
(1998) [4]
Nagino et al. (1998)
[14]
Wu et al. (1999) [11]
Cherqui et al. (1999)
[15]
Scudamore et al.
(2000) [12]
Yamashita et al.
(2001) [16]
Wu et al. (2002) [17]
Hu et al. (2003) [9]
Chouillard et al.
(2003) [18]
Chen et al. (2006)
[19]
Kim et al. (2006)
[20]

Resected
segments

LoE

Characteristics and results of studies of multisegmental (X2 segments) central liver resection.

Study (year)a

Table 1

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C. Stratopoulos et al.

Please cite this article as: Stratopoulos C, et al. Central hepatectomy: The golden mean for treating central liver tumors? Surg Oncol
(2007), doi:10.1016/j.suronc.2007.05.002

ARTICLE IN PRESS

52/63e

18/43d

2b

2b

2b
2b

Wu et al. (1999) [11]

Scudamore et al.
(2000) [12]
Scudamore et al.
(2000) [12]
Hu et al. (2003) [9]

LoE, level of evidence; HCC, hepatocellular carcinoma; CRM, colorectal metastases; CC, cholangiocellular carcinoma; GBC, gallbladder carcinoma; BL, benign lesion and NA, not
assessed.
a
Studies are ordered according to year of publication.
b
Mesohepatectomy (segments 4, 5 and 8) versus extended hepatectomy (14 right, 11 left).
c
Mesohepatectomy (segments 4, 5 and 8) versus lobar hepatectomy (39 right, 32 left).
d
Mesohepatectomy (segments 4, 5 and 8) versus extended hepatectomy (32 right, 11 left).
e
36 mesohepatectomies (segments 4, 5 and 8) and 16 right anterior sectionectomies (segments 5 and 8) versus 56 lobar hepatectomies (36 right, 20 left) and 7 extended hepatectomies
(4 right, 3 left).
 Statistical signicant.

NA
NA
NA
4.4/4.4
51/47
17/19
0/3

45/39
914/1628
0/0

50/48

NA

3.9/5

9/16

131/58
45/30
14.9/16.8
9/10
2450/1863
914/1025
7.9/5.8
3.9/3.7
NA
NA
20/24
50/40
0/4
0/2

HCC
HCC,
GBC,
HCC,
GBC,
HCC
15/25b
18/71c

CRM,
BL
CRM,
CC

Median survival
(month)
Total early
complication
rates (%)
Operative
mortality (%)
Indication
No. of patients
LoE
Study (year)a

Table 2

Non-randomized trials comparing central hepatectomy and lobar or extended hepatectomy.

Mean operative
time (h)

Mean blood
loss (ml)

Post-operative
hospital stay
(day)

Vascular
occlusion time
(min)

Central hepatectomy: treating central liver tumors?

7
have three times greater risk of hepatic dysfunction [24].
However, the permissible extent of hepatectomy is greatly
restricted in cirrhotic livers. A combination of the triphasic
CT volumetric measurements of the liver and the ICG R15
has been found to be useful to predict the safe limits of
hepatectomy in patients with impaired liver function [25].
For patients with a diseased liver, only those with an ICG R15
less than 20% are selected for central hepatectomy because
the residual liver parenchyma is approximately 5060% of
the total liver volume [11].
Three-dimensional CT reconstruction of the liver can help
identify and map the variations of the intrahepatic vascular
structures and their relationship to tumors. Areas at risk for
either devascularization or venous congestion may be
identied prior to liver resection [26]. This is particularly
important for resections that involve the middle hepatic
vein (extended and central liver resections).
Though less extensive than extended hepatectomies,
central liver resections are technically more demanding,
since they require more extensive dissection of vascular
pedicles and larger transection surfaces [18]. Hence, it is
advisable that such resections are performed at major
centers with sufcient experience of liver surgery. Several
studies (see Impact of different techniques of vascular
occlusion on operative blood loss) used vascular occlusion
techniques to control bleeding from the two wide resection
planes during parenchymal transection, although this can be
accomplished without hepatic inow occlusion [27]. In one
study, central liver resections were dened as having high
risk for the development of postoperative bile leakage [16].
They are less likely to develop postoperative liver dysfunction due to maximal preservation of functional parenchyma,
and may also provide increased opportunity to perform
repeated resections [4,18,27,28].
There is sufcient evidence (see Studies of multisegmental central liver resection) to conclude that central
hepatectomy is a safe, feasible and effective option for the
treatment of centrally located liver tumors. Though the
evidence supporting this recommendation is limited and of
low quality, it seems reasonable to recommend a lessextensive procedure that is shown to be safe and equally
effective at resecting the tumor. There are accumulating
data that segment-oriented resection provides several
advantages over extended hepatectomy for both cirrhotic
and non-cirrhotic patients without compromising surgical
radicality.

Conclusion
Central hepatectomy is an acceptable, safe surgical method
for treatment of centrally located liver tumors in noncirrhotic patients, and should be considered in favor of an
extended hepatectomy. It is the procedure of choice in
patients with compromised liver function.

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Please cite this article as: Stratopoulos C, et al. Central hepatectomy: The golden mean for treating central liver tumors? Surg Oncol
(2007), doi:10.1016/j.suronc.2007.05.002