Techniques of Exposure, Hilar Dissection, and

Parenchymal Division in Hepatic Surgery

William C. Chapman, MD, J. Kelly Wright, MD, Paul E. Wise, MD,
and C. Wright Pinson, MD, MBA

A number of methods for hepatic parenchymal transec- experience, and personal preference. Although each method
tion facilitate ligation and division of hepatic vessels may have slight advantages in specific circumstances, expe-
and biliary ducts in the plane of resection. Each represents a rienced liver surgeons can usually successfully complete the
tool available to the liver surgeon, depending on training, parenchymal transection using various techniques.

SURGICAL TECHNIQUE

Exposure

Proper exposure is crucial to the safety, ease, and
efficiency of any operative procedure. This is no less
true for hepatobiliary procedures because of the size
and location of the liver and its proximity to major
vascular structures. Surgeons have developed numer-
ous abdominal and thoracic incisions to provide ade-
quate access to the entire surface of the liver. In addi-
tion, by using self-retaining retractor systems, the sur-
geon can obtain and maintain adequate exposure with-
out depending on fatigable and nonstationary assis-
tants. Performing complete dissection of the liver's
ligamentous attachments can then provide even better
exposure by achieving increased mobility of the organ
and the surrounding viscera.

From the Division of Hepatobiliary Surgery and Liver Transplantation, Depart-

ment of Surgery, Vanderbilt University Medical Center, Nashville, TN.
Address reprint requests to C. Wright Pinson, M.D., M.B.A., F.A.C.S, Depart-
ment of Surgery, Division of Hepatobiliary Surge D, and Liver Transplantation,
Oxtord House, Suite 801, Vanderbilt University Medical Center, Nashville, TN
37232-~-753.
Copyright 2002, ElsevierScience(USA).All rig)itsreserved
1524153X/02/0401-0002535.00/0
doi:10.1053/otgn.2002.30437

Operative Techniques in General Surgery, Vol 4, No 1 (March), 2002: pp 13-32 13

14 Chapman et al

1 Obtaining exposure begins with proper positioning of the patient. This depends
on the type of procedure planned and the portion of the liver to be approached. Most
right-sided resections (segments V-VIII and trisegmentectomies) are best carried out
with the patient in a slightly left-side decubitus position, with a bag or roll used to
elevate the right side 15-30 degrees. Medial or left-sided resections (segments II-IV)
and biliary procedures are usually most easily performed with the patient in the
supine position. For either of these procedures, at the surgeon's discretion the pa-
tient's arms can be positioned out or tucked and the bed can be extended to further
improve exposure.
Exposure, Hilar Dissection, and Parenchymal Division ]5

extension

;tension

Thoracic exter

Subcos

f~ :ii!!!!i!i!!!~ii~84

2 The surgeon can choose from a number of incisions based on the planned procedure. Little
literature has been dedicated to the choice of incision when performing hepatobiliary procedures.l'2"3
Thus, most surgeons' preferences are based on their training. The upper midline incision has been
favored by most surgeons for traumatic liver injuries 4 and by some surgeons for elective cases on the
biliary tract and left lobe of the liver. This incision provides limited access to the right side of the liver,
may provide limited exposure in obese patients or those with a short distance between the xiphoid and
the umbilicus, and has a significant incidence of ventral herniation postoperatively. ~ Paramedian,
Kocher, and interneural right upper quadrant incisions have also been popular for some biliary
procedures, but they have only limited usefulness because of the limited exposure of the liver that they
afford. The bilateral subcostal incision is the most popular incision among hepatobiliary surgeons. 5'6
This incision allows for exposure of the supra-, retro-, and infrahepatic vena cava, excellent exposure of
the porta hepatis, and room for complete mobilization of the liver if necessary. Beginning any right
upper quadrant procedure with an 8 to 10-cm incision approximately 3 - 4 cm (two fingerbreadths)
inferior to the right costal margin allows for quick and easy assessment of the upper abdomen for the
presence of metastases, the extent of local pathology, resectability, and any anomalous anatomy. The
incision can then be extended to the right and left subcostal regions as needed to provide improved
exposure. Alternatively, laparoscopy may allow a quick, minimally invasive assessment of peritoneal
metastases and can be combined with laparoscopic ultrasonography to provide more detail as to the
number and location of hepatic tumors and their resectability.
16 Chapman et al

Rectus sheath

2 (continued) A perpendicular midline extension to the xiphoid also improves mobilization of the
thoracic and anterior abdominal walls, especially in patients with narrow costal angles. Excision of the
xiphoid may prove useful (B). A thoracic extension of the right subcostal incision into the sixth or
seventh intercostal space provides excellent exposure of the right suprahepatic and posterior liver but
increases morbidity from postoperative pulmonary complications. 3,r We have found that appropriate
use of the bilateral subcostal incisions with the midline extension and adequate retraction makes the
thoracic extension unnecessary. 8 Some authors have also suggested turning the midline xiphoid
extension into a full sternotomy to further increase suprahepatic exposure, 9 but this is seldom neces-
sary unless the heart or supradiaphragmatic vena cava must be exposed. Once the initial celiotomy is
complete, the ligamentum teres hepatis (round ligament) within the falciform ligament can be ligated
and divided. This allows for complete opening of the wound and placement of the surgeon's choice of
self-retaining retractor. Surgical assistants with hand-held retractors are not always available in all
operating facilities in sufficient numbers (two or three may be needed), are fatigable, and may find it
difficult to remain steady. In addition, the number of assistants needed to retract often restricts the
surgeon at an overcrowded operating table. For these reasons, we encourage the use of a self-retaining
retraction system. Different retractor systems are available, each with its individual advantages and
disadvantages. 10.11,12
Exposure, Hilar Dissection, and Parenchymal Division 17

3 We have chosen the split-ring Bookwaher self-retaining retractor because of its ease
of assembly and adjustment and have found it quite effective in providing adequate
traction and countertraction when performing hepatobiliary procedures. 8 To use this
system, a table post with a 30 to 45-degree extension bar is fixed over the drapes to the
right siderail of the table at the patient's nipple line. A rod is suspended from this
apparatus to hold the segmented ring, which is centered over the liver and tilted at 45
degrees.
18 Chapman et al

4 The tilt in the ring allows for elevated cephalad retraction of the thorax along with caudal
retraction of the other viscera. This is performed with a Balfour blade with a tilting ratchet in
the upper midline along with three or more right-angle blades (depending on the incision
size) on the costal margins to elevate the thorax and flatten the diaphragm. This is usually
sufficient to provide access to the diaphragm and suprahepatic cava when caudal retraction
on the liver is applied (A).
Exposure, Hilar Dissection, and Parenchymal Division 19

Falciform ligament divided

'\. 3 . , . 84,
J

i
/- J

• Portal triad

< 3

9iii'. , h'>- " " .... ~Jf

B =!

4 (continued) Malleable retractors placed on the inferior portion of the ring can be used to
retract the stomach and duodenum to the left and the hepatic flexure of the colon caudally and to
the right out of the operative field, providing excellent exposure of the porta hepatis (B).
20 Chapman et al

/ Falciform ligament

m / Right
riangular
ligament

A Bare area

(A, B) Once the retractor is in place, the liver can be further mobilized with division of the
ligamentous attachments superiorly and posteriorly (Shown here from above and looking caudally).
These suspensory ligaments, including the left and right triangular ligaments and the anterior and
posterior coronary ligaments, form a triangular or diamond-shaped area along the posterior aspect of
the liver that corresponds to the bare area of the liver and contains the retrohepatic inferior vena cava
and hepatic veins.
Exposure, Hilar Dissection, and Parenchymal Division 21

IVC & hepatic veins

Anterior coronary ligament

Left triangular ligament

., Falciform ligament

Tissue
corresponding
to bare area
of liver

Right
triangular
ligament

\ Portal triad

Posterior coronary
B ligament

(continued)
22 Chapman et al

Right hepatic vein

Adrenal ve

Adrenal gla

6 Careful division of these ligaments allows for elevation and rotation of the liver
to provide access to the posterior right lobe of the liver, the retrohepatic cava, the
right adrenal gland, and the right adrenal vein. Easy visualization and access to these
structures provides a safe means of achieving sufficient vascular control before any
resection. Access to and control of lesser hepatic veins emptying into the retrohe-
patic interior verla cava can be achieved. But hepatic rotation must be carefully
performed, not only because the liver can be damaged with compression against any
of the sharp retractor blades, but also because the liver might fracture, especially in
patients with a friable or fatty liver.
Exposure, Hilar Dissection, and Parenchymal Division 23

7 Laparoscopy is increasingly used in hepatic resections of segments II- VI. 13'14 The subject and
controversies of laparoscopic-assisted liver resections are discussed in detail in other articles in this
issue, but obtaining adequate exposure is no less important in laparoscopic liver procedures than in
those performed in an open fashion. Again, the process begins with proper positioning, depending on
the area of liver in focus. For resections of segments 11, III, IVa, and V, the patient is placed supine with
the legs separated so that the surgeon may stand between the legs (A). For resections of segment VI, the
patient is best placed in the left lateral decubitus position (B). Twenty degrees of reverse Trendelenburg
position can improve the exposure for laparoscopic resections by causing the free abdominal viscera to
mobilize toward the pelvis. Exposure is further augmented with excision of the falciform and left
triangular ligaments to the inferior vena cava for resections of segments II-IVa. Partial excision of the
right triangular and posterior coronary ligaments facilitates the resection of segments V or VI.
24 Chapman et al

Hilar Dissection

Extrahepatic dissection and control of the porta quate biliary drainage. These major resections include
hepatis vessels and bile ducts will facilitate major he- lobectomies, extended lobectomies, and those liver re-
patic resections by limiting bleeding and ensuring that sections of lesions situated in close apposition to hilar
the remaining liver is fully vascularized and has ade- structures.

8 A full understanding of the relational anatomy of the structures in the

hepatoduodenal ligament and hepatic hilum is imperative for safe liver
resection. In general, the bile duct occupies the anterior right porta hepa-
tis. At the inferior liver edge is a confluence of a transversely oriented left
hepatic duct and a more axially oriented right hepatic duct, which de-
scends as the common hepatic duct (CHD) to join the cystic duct at the
inferior border of the triangle of Calot and become the common bile duct
(CBD). The proper hepatic artery generally approaches the liver in the left
anterior porta hepatis and branches into right and left hepatic arteries in
the hepatic hilum. The right hepatic artery usually passes posterior to the
CHD (85%) before entering the liver. The portal vein lies in the posterior
porta hepatis, and its primary bifurcation is at the inferior edge of segment
IV. 15
Exposure, Hilar Dissection, and Parenchymal Division 25

Left
Replaced righl
artery

artery

a~

Right artery

.~ry

artery

9 A significant variability exists in the arterial and biliary anatomy that needs to be antici-
pated and defined during dissection of the porta hepatis. A replaced right hepatic artery may
arise from the superior mesenteric artery and ascend in the right posterior porta behind the
CHD and CBD in 20% of patients. With similar frequency, a replaced left hepatic artery may
arise from the left gastric artery and cross the gastrohepatic ligament to enter the left liver
outside the porta hepatis. Wide variation in the locations of sectoral bile ducts and their
confluences may be seen; for example, major sectoral ducts of the right liver may join the left
hepatic duct peripheral to the primary bifurcation or may descend in the porta to join the CHD
or CBD distally. 16'17
26 Chapman et al

I-I

Principal plane

1 0 Further variability of the anatomy of the porta hepatis can

arise if the liver has undergone sectoral or lobar atrophy and/or
hypertrophy. Rotational distortion of the relational anatomy of the
hepatoduodenal ligament can hinder exposure of the hepatic hi-
lum. as (Shown here as left-sided hypertrophy) In patients with
adhesions and scarring from previous surgery in the porta hepatis,
dissection of the hepatoduodenal ligament can be tedious. Careful
division of the adhesions between the hepatic flexure of the colon
and the liver, mobilization of the duodenum, and intermittent pal-
pation of the region of the porta hepatis to identify hepatic artery
pulses can facilitate approaching the hepatoduodenal ligament from
the right in anticipation of exposing the CBD as an initial landmark.
Exposure, Hilar Dissection, and Parenchymal Division 27

Gall

Hepatic artery

~ry
Portal vein

Bile duct

1 1 Hilar dissection for liver resection generally begins with cholecystectomy and exposure of the triangle of Calot
to facilitate early identification of the CHD-CBD junction. Further incision across the peritoneum of the porta hepatis
allows for progressive exposure and isolation of the primary branches of the hepatic artery and hepatic duct at the
hilum of the liver. At times, exposure of the hilar structures is improved by the incision of Glisson's capsule and
elevation of segment IV (quadrate lobe). This dissection within the hilar plate can be carried out peripherally to gain
control of segmental vascular and bilary branches as necessary for the anticipated parenchymal resection. Lobar or
sectoral divisions of the portal triads, enveloped in a sheath of fibrous tissue originating from Glisson's capsule, can be
defined during parencymal dissection and ligated en masse. ~9 Exposure and control of portal vein branches may be
easier after bile duct and hepatic artery branch ligation and division. Additionally, portal vein isolation is facilitated by
full mobilization of the liver and rotation of the liver to the left to better expose the right posterior aspect of the porta
hepatis.
28 Chapman et al

12 Occasionally, liver resection is part of the management of a proximal bile

duct tumor. Because of the close proximity of the hilar biliary tumor and the
hepatic artery, the portal vein, and their branches, exposure of these vascular
structures can be difficult. Circumferential dissection and division of the CBD
distally allows for the anterior reflection of the CBD and CHD with adjacent
neural and lymphatic tissues to skeletonize the hepatic artery and portal vein
cephalad towards the hilum of the liver. 19
Exposure, Hilar Dissection, and ParenchymalDivision 29

artery

Portal vein

1 3 Alternatives to extensive hilar dissection for liver resection include extrahepatic occlusion of the
hepatoduodenal ligament (Pringle maneuver) (A) and total vascular isolation (B).
30 Chapman et al

Parenchymal Division

14 After abdominal exploration and exposure of the liver and hilar dissection, the final phase of
liver resection is completed with parenchymal division. There are a number of techniques that have
been developed to facilitate this portion of the procedure. Because of the extensive vascular and bile
duct network within the liver, the goal of parenchymal division is to expediently dissect and ligate
hepatic vessels and bile ducts in the plane of transection with minimal blood loss. 21 Portal venous
tributaries are enveloped by Glisson's capsule, making them somewhat resistant to traumatic injury
during the parenchymal transection. In contrast, hepatic venous branches may be thin walled and can
be more easily avulsed during manipulation. The specific techniques used to dissect hepatic tissue away
from vessels and bile ducts depend on the surgeon's preference and experience and by available
technology within the surgeon's hospital setting. Temporary hepatic inflow occlusion (Pringle clamp-
ing) or complete vascular isolation are other techniques that may be used selectively to lessen blood loss
during parenchymal division. 22'23 (A) Finger fracture (digitoclasia) parenchymal division has been the
most widely used and is perhaps the simplest technique for parenchymal division in liver resection. 24
This technique is performed by initially incising the liver capsule along the planned resection plane,
usually with electrocautery. After the liver capsule has been incised, the dissection is initiated with a
blunt instrument (e.g., scissor tip or blunt clamp) by working through the parenchymal tissue. Vessels
and bile ducts can be individually identified, encircled, and either suture ligated or divided with surgical
clips. Many surgeons prefer to suture ligate ducts and larger vessels on the remnant liver side of the
division and use surgical clips only on the specimen side, because clips may become dislodged during
liver manipulation as the resection proceeds. Finger fracture techniques can also be combined with
other methods of parenchymal division. The advantages of the finger fracture dissection technique are
its simplicity and speed. This technique does not require sophisticated instrumentation that may be
unavailable in some operative centers. The disadvantage of the finger fracture technique is the potential
decrease in operative precision. Some authors have reported an increased blood loss using finger
fracture compared with other methods, including ultrasonic dissection 25 (see below). However, one of
the only reported randomized, prospective controlled trials comparing finger fracture dissection with
ultrasonic dissection found no differences in operative blood loss, and the authors claimed that
operative precisionwas actually improved with the finger fracture technique. 24
Exposure, Hilar Dissection, and Parenchymal Division 31

14 (continued) (B) The ultrasonic aspirator is a popular method among many liver surgeons for
parenchymal transection. This device uses an ultrasonic dissector to lyse hepatic parenchyma while
preserving the integrity of vascular and biliary structures within the substance of the liver. This
technique is intended to allow precise visualization and dissection of portal venous and hepatic venous
branches, which can then be individually ligated and divided. Available systems can incorporate
electrocautery as a component in the ultrasonic dissection, facilitating division of small vessels and bile
ducts during liver transection. Disadvantages of these systems include the relatively high system
purchase cost ($60,000-$100,000) and the cost of disposables required on a per case basis ($500-
$1,000). Moreover, parenchymal transection using ultrasonic dissection is usually slower than finger
fracture transection or the use of other mechanical devices. Surgical staplers have been used during
open and laparoscopic liver resections. 26 Vascular staplers generally are 3 0 - 4 5 mm long and can be
placed across sections of parenchymal tissue that are then stapled and automatically divided. Surgical
staplers are usually used in conjunction with another method of parenchymal division, such as finger
fracture division. Vascular staplers can also be used for division of extrahepatic portal and hepatic
venous branches.26 During laparoscopic liver resection, staplers generally require a 12- or 15-mm port
for placement. Currently available articulating vascular staplers facilitate stapler placement on selected
tissue in both laparoscopic and standard open liver resection cases. Several emerging technologies have
potential use in hepatic parenchymal transection, including ultrasonically activated scalpels, controlled
bipolar vessel occluders, and methods of collagen sealing using radiofrequency (RF) current. The
ultrasonically activated scalpel is a surgical instrument that cuts and coagulates tissue, using ultrasonic
energy to denature tissue protein and seal vessels and bile ducts. This instrument uses a power
generator to drive the acoustic system in the handpiece, transmitting ultrasonic energy to blades that
optimize tissue cutting or coagulation. Controlled bipolar systems can be used to obliterate arteries and
veins up to 7 mm in diameter. New devices apply bipolar energy through a clamp for a controlled time
interval, ensuring complete vessel occlusion. Additional technologies (Tissue Link) include RF energy
systems that use RF current to fuse collagen and induce hemostasis at various tissue sites, including the
liver parenchyma during resection procedures. The specific role of these emerging technologies in liver
resection, and their cost-effectiveness, have not yet been fully defined, but remain an area of active
investigation at many centers.
32
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