Overview
Definition:
Segment 2/3 left lateral sectionectomy is an open surgical procedure involving the removal of liver segments II and III, which constitute the left lateral section of the liver
This procedure is typically performed for localized neoplastic or benign lesions within these segments, or for anatomical resection in conjunction with other liver procedures.
Epidemiology:
The frequency of this specific resection depends on the prevalence of pathologies affecting the left lateral segment, such as hepatocellular carcinoma, colorectal liver metastases, cholangiocarcinoma, or benign tumors like adenomas and hemangiomas
Incidence is generally low, reserved for specific indications.
Clinical Significance:
This resection is crucial for achieving oncological clearance for tumors confined to the left lateral section while preserving adequate residual liver volume
It allows for precise removal of diseased tissue, minimizing damage to the remaining functional liver parenchyma and critical vascular structures
Expertise in this specific resection contributes to improved patient outcomes in hepatobiliary surgery.
Indications
Oncological Indications:
Resectable primary liver tumors (e.g., hepatocellular carcinoma, cholangiocarcinoma) confined to segments II and III
Isolated metastases from other primary sites (e.g., colorectal cancer, neuroendocrine tumors) to segments II and III
Suspicious lesions in segments II/III requiring diagnostic biopsy and resection.
Benign Conditions:
Large or symptomatic benign tumors (e.g., hepatic adenoma, hemangioma) in segments II or III that are unsuitable for less invasive techniques
Recurrent pyogenic cholangitis or abscesses in segments II/III unresponsive to conservative management.
Anatomical Considerations:
In some cases, this resection may be part of a more extensive liver resection, such as an extended left hepatectomy, for tumors involving multiple segments
It can also be used for anatomical wedge resection when precise margin control is essential.
Contraindications:
Significant cirrhosis with impaired liver function (Child-Pugh B/C)
Unresectable disease (e.g., extensive vascular involvement, multifocal disease)
Poor performance status
Patient refusal or inability to tolerate major surgery.
Preoperative Preparation
Patient Assessment:
Thorough history and physical examination
Assessment of comorbidities, particularly cardiovascular and pulmonary function
Nutritional status evaluation.
Liver Function Tests:
Comprehensive liver function tests including albumin, bilirubin, prothrombin time/INR
Calculation of Child-Pugh score and MELD score
Assessment of indocyanine green (ICG) retention test to evaluate hepatic functional reserve and predict post-operative liver failure.
Imaging Studies:
Contrast-enhanced CT scan (arterial, portal venous, delayed phases) and MRI with gadolinium for precise lesion localization, vascular anatomy (hepatic veins, portal vein branches, hepatic artery), biliary tree anatomy, and assessment of surrounding structures
Angiography may be useful in select cases to delineate vascular anatomy
Virtual reality reconstruction of liver anatomy can aid surgical planning.
Anesthesia Considerations:
General anesthesia with adequate venous access
Invasive hemodynamic monitoring (arterial line, central venous pressure) is often necessary
Blood transfusion availability and preparation for potential massive hemorrhage.
Surgical Planning:
Detailed surgical plan including planned incision, sequence of vascular and biliary control, planned dissection planes, and method for achieving hemostasis
Intraoperative ultrasound is essential for confirming lesion location and extent
Discussing the case in a multidisciplinary tumor board.
Procedure Steps
Incision And Exploration:
Surgical incision (e.g., right subcostal, midline laparotomy) to allow adequate exposure of the liver
Careful intra-abdominal exploration to confirm resectability and rule out unexpected findings
Intraoperative ultrasound to precisely locate the tumor and assess its relationship to surrounding structures.
Mobilization Of Left Lobe:
Division of the falciform ligament and gastrohepatic ligament to mobilize the left lobe
Identification and dissection of the left hepatic vein and its tributaries draining segments II and III
Ligation and division of the portal vein branches supplying segments II and III
Ligation and division of the left hepatic artery branches supplying the segments.
Biliary Dissection:
Identification and division of the biliary radicles draining segments II and III
This requires meticulous dissection to avoid injury to the common hepatic duct or other important biliary structures
Often visualized using intraoperative cholangiography.
Parenchymal Dissection:
Execution of the resection line using an energy device (e.g., ultrasonic dissector, harmonic scalpel) or cautery
The plane of resection follows anatomical landmarks or is guided by intraoperative imaging
Careful control of bleeding from the cut surface of the liver (glissonian sheath approach can be utilized).
Liver Transection And Hemostasis:
The liver parenchyma is transected along the planned resection margin
Hemostasis is meticulously achieved using electrocautery, hemostatic agents (e.g., Surgicel, Floseal), and sutures
The hepatic veins are ligated securely
Any visible bile leaks are controlled with sutures or fibrin glue.
Closure:
Inspection of the resection bed for bleeding and bile leakage
Placement of drains (e.g., passive or active suction drains) in the subhepatic space
Abdominal closure in layers.
Postoperative Care
Monitoring:
Close monitoring of vital signs, urine output, and fluid balance
Frequent assessment for signs of bleeding (tachycardia, hypotension, decreasing hemoglobin) and bile leak (bilious drainage from drains, abdominal pain, fever).
Pain Management:
Adequate analgesia, typically using patient-controlled analgesia (PCA) with opioids, or epidural anesthesia
Non-opioid analgesics and adjuncts are also utilized.
Nutritional Support:
Early enteral nutrition is encouraged as tolerated to promote gut healing and improve liver regeneration
Parenteral nutrition may be required if enteral feeding is not feasible
Monitor for electrolyte imbalances and manage appropriately.
Laboratory Monitoring:
Serial monitoring of complete blood count, liver function tests (bilirubin, ALT, AST, albumin, INR), and electrolytes
Monitor amylase and lipase to rule out pancreatitis, especially if pancreatic mobilization was involved.
Mobilization And Discharge:
Early mobilization is crucial to prevent complications like deep vein thrombosis and atelectasis
Drains are typically removed when output is minimal (<20-30 mL/24h) and the fluid is not bilious
Discharge criteria include tolerance of oral intake, pain control, and stable vital signs.
Complications
Early Complications:
Hemorrhage (intraoperative or postoperative), bile leak (biloma, biliary peritonitis), hepatic insufficiency (acute liver failure), wound infection, intra-abdominal abscess, pancreatitis, atelectasis, pneumonia, deep vein thrombosis, pulmonary embolism.
Late Complications:
Biliary strictures, biliary fistulas, portal hypertension (if significant portion of liver removed), recurrence of tumor, incisional hernia, adhesions, chronic pain.
Prevention Strategies:
Meticulous surgical technique, precise vascular and biliary control, adequate hemostasis, careful parenchymal transection
Preoperative assessment of liver reserve (ICG), judicious use of drains, early mobilization, and prophylactic antibiotics
Adherence to strict oncological principles for tumor resection.
Prognosis
Factors Affecting Prognosis:
The prognosis is highly dependent on the underlying pathology (benign vs
malignant), stage of disease (for malignant tumors), margin status of resection, and the patient's overall health and liver reserve
For benign conditions, complete resection usually leads to excellent outcomes.
Outcomes:
For benign lesions, prognosis is excellent with complete cure
For malignant tumors, survival rates vary widely based on type and stage
For hepatocellular carcinoma, outcomes are best with early-stage disease and complete resection with clear margins
For metastatic disease, prognosis depends on the primary tumor and extent of systemic disease.
Follow Up:
Regular follow-up is essential, especially for oncological indications
This typically includes clinical examination and cross-sectional imaging (CT or MRI) every 3-6 months for the first 2-3 years, then annually thereafter, to monitor for recurrence or new lesions
Liver function tests are also monitored.
Key Points
Exam Focus:
Key anatomical structures of the left lateral section (segments II & III)
Indications for segment 2/3 resection
Importance of preoperative liver function assessment (ICG)
Potential complications like bile leak and hepatic insufficiency
Oncological principles for clear margins.
Clinical Pearls:
Use intraoperative ultrasound extensively for precise localization and assessment of vascular/biliary structures
Mobilize the left lobe adequately before committing to transection
Secure ligation of hepatic veins is critical to prevent immediate hemorrhage
Careful inspection for bile leaks at the end of the procedure is paramount.
Common Mistakes:
Inadequate mobilization leading to compromised exposure
Injury to the left hepatic vein or major portal venous/biliary branches
Incomplete resection leading to positive margins
Underestimating the risk of hepatic insufficiency in patients with compromised liver function
Failure to achieve meticulous hemostasis.