Overview
Definition:
Right anterior sectionectomy is a specific type of hepatic resection that involves the removal of segments 5, 6, 7, and 8 of the liver
This procedure targets a significant portion of the right lobe, including its anterior segments, and is typically performed for localized lesions or diseases affecting these specific anatomical areas.
Epidemiology:
The prevalence of indications for right anterior sectionectomy is linked to the incidence of primary liver cancers (hepatocellular carcinoma, cholangiocarcinoma) and liver metastases, particularly from colorectal cancer
These conditions have varying epidemiological profiles based on geographic location, risk factors (e.g., hepatitis B/C, cirrhosis, genetic predisposition), and screening practices
The precise incidence of this specific resection is not tracked independently but falls under major hepatectomies.
Clinical Significance:
This procedure is crucial for achieving complete tumor resection in cases of malignancy confined to the right anterior segments of the liver, offering a chance for cure or prolonged survival
It is a technically demanding operation requiring precise anatomical knowledge of the liver's segmental anatomy, vascular supply, and biliary drainage to minimize morbidity and mortality, making it a vital topic for surgical trainees preparing for DNB and NEET SS examinations.
Indications
Surgical Indications:
Primary liver tumors (HCC, cholangiocarcinoma) originating in or predominantly involving segments 5-8
Metastatic disease (e.g., colorectal, neuroendocrine tumors) confined to segments 5-8
Benign liver tumors (e.g., large adenomas, hemangiomas) causing symptoms or posing a risk of rupture within these segments
Segmental biliary strictures or abscesses that cannot be managed conservatively
Pre-transplant resection for specific indications.
Contraindications:
Extensive tumor involvement of the remaining liver parenchyma
Unresectable contralateral lesions
Inadequate future liver remnant (FLR) volume
Severe decompensated cirrhosis (Child-Pugh C)
Significant comorbidities precluding major surgery
Uncontrolled portal hypertension
Distant metastases.
Patient Selection:
Careful patient selection is paramount
This involves thorough preoperative assessment including liver function tests (LFTs), assessment of liver volume using CT volumetry (calculating FLR), evaluation of vascular involvement (portal vein, hepatic vein), and staging of malignancy
Multidisciplinary team discussion is essential.
Preoperative Preparation
Diagnostic Workup:
Comprehensive imaging: contrast-enhanced CT scan (essential for 3D reconstruction, tumor mapping, FLR assessment), MRI with liver-specific contrast for better characterization of lesions
Portal venography or MR angiography to assess vascular anatomy
Ultrasound for initial detection and guidance
Tumor markers (e.g., AFP, CEA, CA 19-9) as appropriate
Biopsy if diagnosis is uncertain and not violating oncologic principles.
Optimization:
Nutritional assessment and optimization
Management of ascites and encephalopathy in cirrhotic patients
Optimization of coagulation status
Prophylaxis for deep vein thrombosis and stress ulcer
Antibiotic prophylaxis
Ensuring adequate hydration and electrolyte balance.
Surgical Planning:
Detailed intraoperative planning based on imaging, including the planned incision, extent of resection, anticipated blood loss, and potential need for vascular reconstruction or liver support
Identification of crucial vascular pedicles and biliary structures
Consideration of open vs
laparoscopic/robotic approach.
Procedure Steps
Approach And Exposure:
Abdominal incision: typically a bilateral subcostal ( கோcher) incision or midline laparotomy, sometimes combined with a right thoracotomy for access to the diaphragm and suprahepatic veins
Careful dissection to expose the liver parenchyma, porta hepatis, and hepatic veins.
Mobilization And Vascular Control:
Mobilization of the liver to allow adequate visualization
Identification and critical control of the inflow vessels (hepatic artery and portal vein branches supplying segments 5-8) and outflow vessels (hepatic vein branches draining segments 5-8)
The plane between segments is often identified and dissected carefully.
Parenchymal Transection:
Parenchymal transection is performed using various techniques: ultrasonic dissectors (e.g., CUSA), harmonic scalpel, electrocautery, or ligature with staplers
The Glissonean sheath or pedicles are ligated as they are encountered
Careful attention is paid to controlling bleeding from hepatic veins and managing biliary radicals
Anatomical resection (following vascular/biliary supply) is preferred for oncologic control.
Hemostasis And Biliary Management:
Meticulous hemostasis is achieved using electrocautery and argon beam coagulation
All visible bile ducts are ligated or clipped
The raw surface is inspected for bile leaks
Drainage catheters are typically placed in the subphrenic space and/or near the resection bed.
Postoperative Care
Monitoring:
Close monitoring of vital signs, urine output, and central venous pressure
Frequent laboratory assessments including LFTs, electrolytes, coagulation profile, and CBC
Monitoring for signs of bleeding, infection, bile leak, and hepatic decompensation (encephalopathy, ascites, jaundice).
Pain Management:
Aggressive pain control using epidural analgesia, patient-controlled analgesia (PCA), or intravenous opioids
Early ambulation to prevent complications.
Nutritional Support:
Early enteral feeding is encouraged as tolerated, ideally within 24-48 hours
Parenteral nutrition may be required if enteral intake is insufficient
Monitoring for malnutrition and providing appropriate dietary modifications.
Complication Management:
Prompt recognition and management of complications such as post-hepatectomy liver failure (PHLF), secondary biliary complications (bile leak, stricture), intra-abdominal abscess, hemorrhage, and pulmonary complications
This may involve re-operation, percutaneous drainage, or supportive medical management.
Complications
Early Complications:
Post-hepatectomy liver failure (PHLF): ranging from mild transient dysfunction to severe organ failure
Biliary leakage: from small bile ducts or cystic duct stump
Hemorrhage: from the resection surface or injured vessels
Intra-abdominal sepsis/abscess
Portal vein thrombosis
Hepatic vein thrombosis
Ascites.
Late Complications:
Biliary strictures
Biliary cirrhosis (rare)
Incisional hernia
Adhesions leading to bowel obstruction
Chronic liver dysfunction or decompensation
Tumor recurrence.
Prevention Strategies:
Accurate FLR calculation and preoperative embolization if FLR is borderline
Meticulous surgical technique with careful control of vessels and bile ducts
Intraoperative ultrasound to assess margins and identify small lesions
Judicious use of drains
Early mobilization and aggressive pain management
Strict adherence to prophylactic antibiotics and DVT prophylaxis.
Prognosis
Factors Affecting Prognosis:
Tumor histology and stage (for malignancies)
Degree of liver resection
Pre-existing liver disease and its severity
Intraoperative blood loss and transfusion requirements
Development of postoperative complications, particularly PHLF
Adequacy of surgical margins.
Outcomes:
For benign conditions, outcomes are generally excellent with complete resolution of symptoms
For malignant conditions, survival depends on the type and stage of cancer
Successful resection of early-stage HCC or limited metastases can lead to long-term survival or cure
Morbidity rates for major hepatectomies are significant but have decreased with improved surgical techniques and patient management, typically ranging from 10-30% for major resections.
Follow Up:
Postoperative follow-up includes regular clinical examinations and laboratory tests (LFTs, tumor markers)
Imaging surveillance (CT/MRI) is crucial to detect early tumor recurrence, typically performed every 3-6 months for the first 2 years, then less frequently
Long-term follow-up for chronic liver disease management.
Key Points
Exam Focus:
Understand the precise anatomical definition of segments 5-8
Differentiate indications for sectionectomy versus lobectomy
Recognize the crucial role of FLR assessment and methods to increase it (e.g., portal vein embolization)
Be aware of key intraoperative challenges: controlling hepatic veins draining the resected segments and securing biliary radicles
Know the common complications, especially PHLF, and their management.
Clinical Pearls:
When performing anatomical resection, trace the vessels and ducts to their origin to ensure complete devascularization and bile duct division within the resected segments
Always confirm adequate FLR before committing to a major resection
Consider using intraoperative ultrasound to confirm margins and identify occult lesions
Judicious use of drains to detect early bile leaks or bleeding.
Common Mistakes:
Inadequate preoperative assessment of liver function and volume
Failure to achieve adequate FLR
Incomplete tumor resection due to poor oncologic margins
Undue haste during parenchymal transection leading to uncontrolled bleeding or bile leak
Misidentification of hepatic vein branches
Overlooking occult contralateral lesions.