Overview
Definition:
Left trisectionectomy, also known as extended left hepatectomy, is a major surgical procedure involving the resection of the left lobe and often segments I, IV, and V of the liver
It is a more extensive hepatectomy than a standard left hepatectomy, aiming for oncological clearance in complex cases involving tumors that extend beyond the anatomical boundaries of the left lobe.
Epidemiology:
The incidence of left trisectionectomy is relatively low, primarily dictated by the prevalence of primary and secondary liver malignancies requiring such extensive resection
Patient selection is critical due to the significant morbidity associated with major hepatectomy
Demographics are typically skewed towards older adults with underlying liver disease or those with advanced cancers.
Clinical Significance:
Left trisectionectomy is crucial for achieving R0 resection in patients with large or strategically located liver tumors that involve both the left and central/right segments
It represents a challenging but potentially curative option for select patients with hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma, or extensive liver metastases, thereby improving survival and quality of life.
Indications
Oncological Indications:
Primary liver tumors (HCC, cholangiocarcinoma) involving segments 1, 2, 3, 4, and potentially 5, requiring complete tumor extirpation
Liver metastases from colorectal, neuroendocrine, or other primaries that are confined to the left lobe and adjacent segments and amenable to complete resection
Resection of benign but symptomatic or precancerous lesions requiring extensive clearance.
Non Oncological Indications:
Rarely indicated for extensive liver trauma or severe congenital anomalies not amenable to less aggressive surgical approaches
Management of complex hepatic abscesses or parasitic infections when conservative measures fail and the lesion is widespread in the left lobe and beyond.
Patient Selection Criteria:
Adequate liver remnant function (assessed by indocyanine green clearance, Child-Pugh score, and future liver remnant volume)
Absence of unresectable metastatic disease outside the liver
Good performance status (ECOG 0-1)
Absence of significant comorbidities that would preclude major surgery
Careful vascular and biliary anatomy assessment.
Preoperative Preparation
Preoperative Assessment:
Detailed imaging (CT, MRI, PET-CT) to delineate tumor extent, vascular involvement, and proximity to major vessels and bile ducts
Portal vein embolization (PVE) for the future liver remnant (FLR) may be considered to induce hypertrophy and improve function prior to resection
Nutritional optimization and management of any underlying liver disease (e.g., viral hepatitis, cirrhosis).
Surgical Planning:
Multidisciplinary team discussion involving hepatobiliary surgeons, radiologists, oncologists, and anesthesiologists
Careful planning of the parenchymal transection line, vascular control (hepatic artery, portal vein, hepatic veins), and biliary reconstruction
Assessment of potential blood loss and need for intraoperative cell salvage.
Anesthesia Considerations:
General anesthesia with careful hemodynamic monitoring
Consideration of epidural analgesia for postoperative pain management
Management of potential coagulopathy and fluid shifts
Maintaining adequate oxygenation and ventilation throughout the procedure.
Procedure Steps
Approach:
Laparoscopic, robotic, or open approach depending on surgeon preference, patient factors, and tumor complexity
Typically involves a bilateral subcostal or Mercedes incision for open surgery.
Mobilization And Exposure:
Extensive mobilization of the liver from the diaphragm, retroperitoneum, and anterior abdominal wall
Identification and isolation of the porta hepatis structures: common hepatic artery, portal vein, and common bile duct
Identification and control of the left hepatic artery, left portal vein, and left hepatic vein (if applicable).
Vascular Control:
Crucial step involving sequential ligation and division of vascular pedicles supplying the resected segments
This may include the left portal vein branches and the left hepatic artery
For extended left hepatectomy, control of the main portal vein or individual segmental branches may be necessary
Hepatic vein control (left hepatic vein or its tributaries) is also essential before parenchymal transection.
Parenchymal Transection:
Performed using various techniques, including ultrasonic dissectors, CUSA (Cavitational Ultrasonic Surgical Aspirator), harmonic scalpel, or electrocautery
Transection is typically guided by intraoperative ultrasound and anatomical landmarks, following the defined resection margins
Careful attention is paid to hemostasis and identification of bile ducts within the transection plane.
Biliary Reconstruction:
After parenchymal transection, any transected bile ducts within the remnant liver need to be reconstructed
This usually involves a hepaticojejunostomy (e.g., Roux-en-Y) to the remnant hepatic duct or a hepaticogastrostomy
For extended left hepatectomy, meticulous reconstruction is vital to prevent biliary leakage or stricture.
Hemostasis And Drainage:
Meticulous hemostasis is achieved by controlling bleeding vessels and ensuring adequate coagulation
Placement of drains (e.g., Jackson-Pratt) in the resection bed to monitor for bile leak or hemorrhage
The abdominal cavity is then closed in layers.
Postoperative Care
Monitoring:
Intensive care unit (ICU) monitoring for hemodynamic stability, respiratory function, urine output, and fluid balance
Frequent laboratory monitoring, including liver function tests, electrolytes, and coagulation profile
Close observation for signs of hemorrhage, bile leak, infection, and post-hepatectomy liver failure (PHLF).
Pain Management:
Aggressive pain control using multimodal analgesia, including IV opioids, patient-controlled analgesia (PCA), and potentially epidural anesthesia
Early ambulation is encouraged to prevent complications like deep vein thrombosis and pneumonia.
Nutritional Support:
Early initiation of enteral nutrition, preferably via nasogastric or post-pyloric feeding tubes, as soon as ileus resolves
Supplementation with branched-chain amino acids may be considered in patients with severe liver dysfunction
Hydration and electrolyte balance are critical.
Complication Management:
Prompt recognition and management of complications such as PHLF, sepsis, biliary leak (biloma, cholangitis), intra-abdominal abscess, ascites, pleural effusion, and coagulopathy
Management may involve fluid resuscitation, antibiotics, drainage procedures, repeat laparotomy, or non-operative interventions.
Complications
Early Complications:
Post-hepatectomy liver failure (PHLF) is the most serious complication, often graded by ISGLS criteria
Biliary leakage or fistula
Intra-abdominal hemorrhage
Sepsis
Bile duct stenosis or stricture
Wound infection
Pneumonia
Acute kidney injury.
Late Complications:
Biliary strictures leading to cholangitis
Incisional hernia
Adhesions
Chronic liver dysfunction
Recurrence of malignancy
Gastric outlet obstruction if hepaticojejunostomy is involved.
Prevention Strategies:
Careful patient selection and optimization of FLR volume and function (e.g., PVE)
Meticulous surgical technique with precise vascular and biliary control
Adequate parenchymal transection margins
Prophylactic antibiotics
Effective postoperative care with vigilant monitoring
Early mobilization and nutritional support.
Prognosis
Factors Affecting Prognosis:
The underlying pathology (benign vs
malignant), stage of the disease, completeness of resection (R0 vs
R1/R2), adequacy of the liver remnant, presence of comorbidities, and development of postoperative complications, particularly PHLF
For malignant lesions, tumor biology, lymph node status, and margin status are critical.
Outcomes:
For benign lesions or limited disease, outcomes can be excellent with high rates of cure and long-term survival
For malignant lesions, survival is highly dependent on the specific cancer type and stage
Achieving R0 resection is paramount for improving survival in oncological cases
Morbidity rates can be significant but are decreasing with advances in surgical techniques and perioperative care.
Follow Up:
Regular postoperative follow-up is essential, including clinical examination, laboratory tests (liver function tests, tumor markers), and imaging (CT, MRI)
Frequency and duration of follow-up depend on the underlying pathology
For oncological indications, close surveillance for recurrence is vital
Surveillance for biliary complications and liver function is also important.
Key Points
Exam Focus:
Understand the indications for extended left hepatectomy and the critical role of FLR assessment
Master the principles of vascular and biliary control during major hepatectomy
Recognize the spectrum of early and late complications, especially PHLF, and their management
Differentiate between standard left hepatectomy and left trisectionectomy based on anatomical involvement.
Clinical Pearls:
Preoperative portal vein embolization is a cornerstone for maximizing FLR hypertrophy and function when a large remnant is anticipated
Intraoperative ultrasound is invaluable for guiding parenchymal transection and identifying subtle vascular structures or tumors
Meticulous biliary reconstruction, often with a Roux-en-Y hepaticojejunostomy, is crucial to minimize biliary complications.
Common Mistakes:
Inadequate FLR assessment leading to PHLF
Failure to secure adequate vascular control before parenchymal transection, causing uncontrolled hemorrhage
Incomplete tumor resection due to poor preoperative planning or intraoperative deviation from planned margins
Insufficient attention to biliary reconstruction, resulting in leaks or strictures
Underestimating the significant fluid shifts and hemodynamic challenges during major hepatectomy.