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Figure 2. Modified Llyod-Davies position. Care must be taken to ensure that the legs sit comfortably in the stirrups to reduce
pressure on the common peroneal nerve. Ideally, the hip is maintained in neutral flexion-extension position to prevent clashing of the
laparoscopic instruments with the patient’s thigh intra-operatively.

Modified Lloyd-Davies position
The modified Lloyd-Davies position with leg stirrups can also be utilised should the straight-leg split
surgical table not be readily available, or should there be a need for access into the pelvis/perineum such as
in the setting of combined colorectal and liver resections for colorectal cancer with liver metastasis [Figure 2].
In both the supine straight split leg or modified Llyod-Davies position, the patient can be placed on a gel
mattress that has anti-slip properties or a vacuum-cushion mattress that is moulded to the patient’s body
contours to prevent the patient from sliding once placed in reverse Trendelenburg or if the surgical bed is
tilted in the left-right axis.

Pneumatic thigh and calf compressors should be utilised to minimize deep venous thrombosis of the lower
limbs, which is particularly important in laparoscopic liver resection wherein patients are subjected to
reverse Trendelenburg positioning for extended periods.

Laparoscopic liver resections for posterior and superior lesions
Left lateral decubitus
The left lateral decubitus is commonly employed for posterior lesions in segment 6, segment 7 and dorsal
aspect of segment 8 [11,12] [Figure 3A and B]. Not only does this position offer better exposure of posterior
segments, but it elevates the right hepatic vein higher than the vena cava, which reduces hepatic venous
bleeding [7,13] . With adjustment of the left-right rotation of the operating table to achieve a more supine
position, the surgeon is allowed flexibility to access the liver hilum for portal inflow isolation or application
of a snare around the hepatoduodenal ligament for the Pringle’s manoeuvre.

Typically, in a full left lateral decubitus position the legs are not split. However, in instances where a full left
lateral decubitus is not required and the surgeon would still like to maintain a split-leg position, one can
modify the original supine split-leg or modified Lloyd-Davies position [Figures 1 and 2] to include a gentle
30 to 45-degree tilt with the use of gelpads placed under the right side of the abdomen.

Semi-prone position - a modification of the left lateral decubitus position
The semi-prone positioning is a modification of the left lateral decubitus position, and has also been
described for right-sided hepatectomies in particular segment 6, 7, 8 resections, posterior sectionectomy,