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Page 2 of 18 Thiruchelvam et al. Hepatoma Res 2021;7:22 I http://dx.doi.org/10.20517/2394-5079.2020.144

A B

Figure 1. Supine straight split-leg position. The right arm is extended on an arm-board (A). The right arm is abducted and flexed
overhead in an arm support, which facilitates port placement for posterior-superior resections (B).

[3]
that the indications for laparoscopic liver resections involving all liver segments have expanded and an
[4-6]
increasing number of centres have adopted it as routine practice .
The liver’s shielded anatomical location beneath the ribs traditionally requires extended subcostal incisions
for surgical access in open surgery, whereas in LLR, ideal patient and port positioning have facilitated
optimal laparoscopic visualization with ergonomical access. The caudal approach is the main paradigm
shift in LLR, in contrast to the anterior approach adopted during open liver resections. These magnified
caudal views not only allow for enhanced and precise parenchymal transection of the liver, but also
facilitate improved exposure of the hilar plate for pedicle clamping, and around the right adrenal gland and
[7,8]
the inferior vena cava for meticulous division of the short hepatic veins .

This article seeks to summarize and illustrate the options available for patient and port positioning in
varying types of LLR, which we believe is an under-described, yet a critical technical aspect in LLR.

PATIENT POSITIONING
The planned liver resection and surgical approach will dictate the ideal patient positioning and port
placement. Liver resections are broadly divided into non-anatomical partial hepatectomies, or anatomical
segmentectomies, sectionectomies or hemihepatectomies, whereby resection lines follow the portal inflow
and hepatic veins. We describe patient positioning in the context of planned surgical resection, as follows.

Laparoscopic liver resection for antero-lateral segments
Supine straight split-leg position
A frequently adopted position for this large subset of LLR is the supine straight split-leg position [Figure 1].
This position facilitates more ergonomical options of standing positions for the primary surgeon and the
assistants, by allowing one to stand between the patients’ legs, and has been affectionately termed the “French
position” [9,10] .

The knees are strapped to prevent buckling when the patient is subsequently positioned in steep reverse
Trendelenburg. Additional foot-holds can prevent the patient from sliding caudally [Figure 1B]. The upper
limbs are typically extended or flexed overhead to allow for more lateral trocar placement, as well as to add
stability to the patient’s position during left-right axis tilting. Arm-boards also provide easy vascular access
to the upper limbs for anaesthesiologic purpose.