Page 133 - Read Online

Kim et al. Hepatoma Res 2021;7:31 https://dx.doi.org/10.20517/2394-5079.2021.09 Page 3 of 7

SELECTION OF APPROACH FOR CAUDATE LOBECTOMY & SURGICAL TECHNIQUES
Different approaches for isolated caudate lobectomy by open approach were reported previously; the
[30]
[31]
posterior or right-side approach by Yanaga et al. , the left-side approach by Colonna et al. , and the
anterior approach by Yamamoto et al. have been commonly used. The type of approach is determined
[32]
depending on the tumor size and location; the left-sided approach is suitable for Spiegel lobe resection and
the posterior or right-side approach is used for paracaval or caudate process lesions. For the case of whole
caudate lobe involvement, the left-sided and right-sided combined approach can be used .
[33]
For left-sided approach, exposure is facilitated through retraction of left lateral section to the right after
division of the falciform, coronary, and triangular ligaments. Once excision of the lesser omentum is
completed, the Spiegel lobe can be seen and the dissection is performed from caudal to cranial and left to
right direction. The hepatocaval ligament covering the retrohepatic IVC is divided to free the left lateral
border and better expose the upper area of the IVC. The Spiegel lobe can then be retracted upward to
expose the short hepatic veins which upon dissection frees the caudate lobe from the retrohepatic IVC. The
portal triads to the Spiegel lobe are then exposed, dissected, and clipped. After that, the liver parenchyma is
transected starting from the caudal side along the IVC up to the border for adequate margin. Division of the
Arantius’ ligament frees the upper boundary of the caudate lobe from segment 4 and aids in isolating the
[29]
confluence of the left hepatic vein into the IVC .

For right-sided approach, the retroperitoneum covering the infrahepatic IVC is divided after right liver
mobilization and the right adrenal gland is detached from the liver. The hepatocaval ligament is divided and
the liver is retracted to the left side to expose the short hepatic veins. The short hepatic veins into IVC are
exposed, clipped and divided from caudal to cranial up to the level of the confluence of the right hepatic
vein into the IVC. Retraction of the hepatoduodenal ligament to the left better exposes the caudate process.
The anterior border of the resection plane is the posterior Glissonean pedicle from which portal branches to
the caudate process can be identified. Ligation of these branches will show the anatomical transection
border and parenchymal transection is carried out up to cranially until the confluence of the right hepatic
[34]
[28]
vein into the IVC is reached . In some cases, counterstaining technique as described by Takayama et al.
may be useful for better delineating the borders.
The transection of the liver parenchyma and management of bleeding can be challenging because of the
deep lying surgical field. Adequate mobilization of caudate lobe allows better visualization, which can
minimize major vascular injury during parenchymal dissection. Meticulous dissection of individual
branches of the portal vein, bile duct and short hepatic veins is important and keeping dissection plane
along the exact anatomical landmark helps reduce bleeding and bile leakage. Energy devices or cavitron
ultrasonic surgical aspirator is usually used. Bipolar eletrocautery especially comes handy when dissection
and managing bleeding from the short hepatic veins since it very effectively controls small bleeding from
veins. Ultrasonography can help to better understand the anatomic location of important vascular
structures such as the middle or right hepatic veins . The interruption of blood inflow by Pringle
[18]
manuever can offer additional bleeding control during the dissection.

LAPAROSCOPIC APPROACH FOR CAUDATE LOBECTOMY
The overall approach and procedures practiced in laparoscopic approach are not different much from open
caudate lobectomy. Small lesions located on the Spiegel’s lobe are most readily approached from the left
side, and lesions requiring the removal of paracaval caudate or the caudate process will need additional
approach from the right side. The indication of purely laparoscopic isolated caudate lobectomy for HCC
regarding tumor size and location is not established yet. However, the location and the size of the tumor are