After reverse L-shaped laparotomy and exploration of the abdominal cavity, the ligamentum tear and the ligamentum sfor are divided. Next, careful bimanual. Exploration of the hepatic ligament is performed to exclude extra hepatic lymph node metastasis.
After dividing the right triangular ligament, a Doppler ultra sonogram is performed to investigate intra hepatic tumor spread and its relation to the main intra hepatic vascular structures, especially the middle hepatic vein, and consequently, to determine the transaction line. If a curative procedure appears possible, the right hemi liver is completely mobilized from the sub innium and from the retro hepatic inferior vena caver by dividing the posterior liver veins between clips or sutures. After isolating the right liver vein, a meline loop is inserted for later lifting of the liver during the parenchymal transection.
Next, the cholecystectomy is performed after a detailed sonogram, and once the course of the middle hepatic vein has been detected, the transaction line is marked by electrocautery. Now, parenchymal dissection is started. The liver is gently held, symmetrically lifted and opened with two towels.
The parenchymal transection is performed with accuser dissector. Small vessels are sealed with water irrigated bipolar forceps, and larger vessels or bile ducts are divided between ligatures clips or even sutures. During the transaction phase, central venous pressure is kept as low as possible to minimize blood loss.
This phase continues until the intrahepatic right pedicle is completely free. Then a meline loop is inserted to lift the pedicle and allow a traumatic introduction of a vascular stapler. Finally, the right pedicle is transected with the stapler and then sharply divided with the knife on the right.
After removing the stapler device, the stump of the right pedicle from the resected lobe is over sewn with a running suture. Then the rest of the parenchymal transaction is completed by suspending the residual parenchyma using the previously placed meline loop. Now the right hepatic vein is dissected with the vascular stapler and the right liver lobe is removed.
This is followed by careful hemostasis of the cut surface and precise exploration to exclude bile leaks. The last step is fixation of the remnant liver lobe.
