Overview
Definition:
Right trisectionectomy, also known as extended right hepatectomy, is an extensive surgical procedure involving the resection of the right lobe of the liver along with the middle hepatic vein
It encompasses the resection of segments V, VI, VII, and VIII, and often the central portion of segment IV, leaving the left lobe and potentially segment I (caudate lobe) intact
This procedure is typically reserved for malignant tumors or extensive benign lesions involving the majority of the right hemiliver.
Epidemiology:
Hepatic resections are performed for a variety of conditions including primary liver cancers (hepatocellular carcinoma, cholangiocarcinoma), metastatic disease (colorectal, neuroendocrine), and benign tumors (adenoma, hemangioma)
The incidence of requiring an extended resection like right trisectionectomy is relatively low, dictated by tumor size, location, and involvement of major hepatic vasculature
Patient selection is critical for favorable outcomes.
Clinical Significance:
Right trisectionectomy represents one of the most extensive hepatectomies, carrying significant morbidity and mortality if not performed in specialized centers by experienced teams
It is a life-saving procedure for patients with otherwise unresectable liver malignancies confined to the right hemiliver
Understanding its indications, operative nuances, and potential complications is crucial for surgical residents preparing for DNB and NEET SS examinations, as it highlights principles of major liver surgery and patient management.
Indications
Malignant Tumors:
Primary hepatocellular carcinoma (HCC) or intrahepatic cholangiocarcinoma (ICC) involving segments V, VI, VII, and VIII, with clear surgical margins achievable
Metastatic disease (e.g., from colorectal or neuroendocrine tumors) to the right hemiliver that is resectable.
Benign Tumors:
Large, symptomatic benign tumors such as giant hemangiomas or adenomas occupying the majority of the right lobe, posing a risk of rupture or significant compression symptoms, and where less extensive resections are not feasible.
Vascular Involvement:
Tumors extensively involving the right hepatic vein or its tributaries, necessitating its sacrifice along with the right lobe for complete oncological clearance
Careful assessment of portal vein and hepatic artery involvement is mandatory.
Patient Selection:
Adequate future liver remnant (FLR) volume, assessed by volumetry (e.g., CT volumetry), is paramount
Patients should have preserved liver function (Child-Pugh A is ideal, carefully selected B may be considered) and no evidence of extrahepatic disease
A multidisciplinary team approach is essential for optimal patient selection.
Preoperative Preparation
Imaging Assessment:
Contrast-enhanced CT scan with portal venous and arterial phases for tumor staging, vascular anatomy assessment, and FLR volumetry
MRI may be used for better soft tissue characterization and vascular detail
Angiography might be considered for complex vascular reconstructions.
Liver Function Tests:
Comprehensive liver function tests including bilirubin, albumin, PT/INR, and AST/ALT
Child-Pugh score and MELD score calculation to assess liver reserve
Indocyanine green (ICG) retention test for a dynamic assessment of liver function.
Portal Vein Embolization:
For extensive resections where FLR is borderline, preoperative portal vein embolization (PVE) of the right portal vein can induce hypertrophy of the left lobe (FLR), increasing future liver function and reducing postoperative liver failure risk
This is typically performed 2-4 weeks prior to surgery.
Nutritional Support:
Optimization of nutritional status, particularly for patients with malnutrition due to liver disease or malignancy
Consultation with a dietician is recommended
Perioperative antibiotics are administered as per institutional protocols.
Procedure Steps
Approach And Exposure:
Typically performed via a subcostal or Mercedes-Benz incision for adequate exposure
Mobilization of the liver starts with division of the falciform ligament, round ligament, and exploration of the suprahepatic and infrahepatic inferior vena cava
Ligamentous attachments of the liver are taken down, and the right triangular and coronary ligaments are divided.
Portal Pedicle Division:
The right portal triad (right portal vein and right hepatic artery) is identified and ligated/divided
Careful dissection is crucial to avoid injury to the left portal system
Intraoperative ultrasound may assist in identifying vascular anatomy.
Hepatic Vein Management:
The middle hepatic vein, which drains the right lobe and separates it from the left lobe, is identified
It is divided between ligatures or using an endoscopic stapler
Identification of the left and right hepatic veins draining into the IVC is critical for understanding vascular planes.
Parenchymal Transection:
Parenchymal transection is performed along the planned resection line, typically using an ultrasonic dissector, harmonic scalpel, or cavitron ultrasonic surgical aspirator (CUSA) to minimize blood loss
Hemostasis is meticulously achieved by controlling small vessels and bile ducts.
Excision And Hemostasis:
The resected specimen (right lobe including middle hepatic vein) is removed
Meticulous attention is paid to achieving complete hemostasis and controlling any bile leaks from the transected surface
Drains are typically placed in the subhepatic space.
Postoperative Care
Monitoring:
Close monitoring of vital signs, fluid balance, and urine output
Intensive care unit (ICU) admission is standard for close observation
Serial monitoring of liver function tests, coagulation profile, and electrolytes is essential.
Fluid And Electrolyte Management:
Aggressive fluid management may be required, but careful attention to avoid fluid overload and hyponatremia is critical
Electrolyte imbalances, particularly potassium and magnesium, should be corrected promptly.
Pain Management:
Adequate analgesia, often with patient-controlled analgesia (PCA), is crucial for patient comfort and to facilitate deep breathing and early mobilization, reducing the risk of pulmonary complications.
Nutritional Support:
Early enteral feeding is encouraged as tolerated, often starting with clear liquids and advancing as bowel function returns
Parenteral nutrition may be necessary if enteral feeding is not feasible or sufficient
Adequate protein intake is vital for liver regeneration.
Complications
Early Complications:
Post-hepatectomy liver failure (PHLF) is the most serious early complication, characterized by coagulopathy and encephalopathy
Biliary leaks (biloma or bile fistula) from transected ducts or the cystic duct remnant
Hemorrhage from the transection surface or hepatic veins
Sepsis, wound infection, and pleural effusion.
Late Complications:
Biliary strictures, hepatic abscess formation, diaphragmatic dysfunction, incisional hernia, and recurrence of malignancy
Adhesions can lead to bowel obstruction.
Prevention Strategies:
Meticulous surgical technique, appropriate patient selection, preoperative PVE for borderline FLR, judicious use of intraoperative ultrasound, achievement of complete hemostasis, and prompt recognition and management of early warning signs are key to prevention
Postoperative management in a specialized unit with experienced nursing staff is crucial.
Prognosis
Factors Affecting Prognosis:
The primary factors influencing prognosis are the type and stage of the underlying disease, the adequacy of surgical margins (R0 resection), the patient's preoperative liver function (Child-Pugh score), and the occurrence of postoperative complications
For malignant tumors, tumor biology and response to adjuvant therapy also play a role.
Outcomes:
In experienced centers, mortality rates for right trisectionectomy can be as low as 5-10%
Survival is highly dependent on the etiology
For HCC, 5-year survival rates can range from 30-50% for resectable tumors
For metastatic disease, survival is dictated by the primary tumor and response to treatment
For benign lesions, prognosis is excellent post-resection.
Follow Up:
Regular follow-up with imaging (CT scan) every 3-6 months for the first 2 years, then annually, is recommended for patients with malignant conditions to monitor for recurrence
For benign conditions, follow-up is guided by symptoms and institutional practice.
Key Points
Exam Focus:
Understand the anatomy of the right hemiliver, including hepatic vein drainage and portal inflow
Recognize the critical role of FLR volumetry and PVE
Be aware of the main indications and contraindications for extended hepatectomy
Identify key complications like PHLF and biliary leaks, and their management principles.
Clinical Pearls:
Always consider the patient's overall liver reserve before contemplating such an extensive resection
Intraoperative ultrasound is invaluable for confirming vascular anatomy and planning the transection plane
Meticulous hemostasis and biliary control are paramount during parenchymal transection.
Common Mistakes:
Inadequate assessment of FLR leading to post-operative liver failure
Failure to identify and manage accessory hepatic veins
Incomplete resection margins (R1/R2 resection)
Underestimation of intraoperative blood loss and inadequate fluid resuscitation
Delayed recognition and management of PHLF.