World J. Surg.

6, 10-24, 1982

of Sdrgery

Major and Minor Segmentectomies "R6gl6es" in Liver Surgery

Henri Bismuth, M.D., Didier Houssin, M.D., and Denis Castaing, M.D.
Unit~ de Chirurgie H~pato-Biliaire, Facult6 de M6decine Paris Sud, H6pital Paul Brousse, Villejuif, France

Individualization of the segment as the functional anatomical unit of the liver permits the performance of surgical segmentectomies. These segmental resections are "r6gl6es" because the plane of cleavage of the hepatic parenchyma follows the anatomical scissurae. From the technical point of view, liver segmentectomies are characterized by an exclusive transparenchymatous approach to the vascular pedicles of the segment to be removed. We have performed this type of surgery in 22 patients with no mortality. These operations are indicated in: (1) some benign tumors; (2) some liver trauma; (3) biliary operations above the hilus, where anterior resection of segment IV can be necessary; and (4) carcinomas of the gallbladder discovered histologically after cholecystectomy. Liver segmentectomies can also be indicated for malignant tumors when the liver is cirrhotic, or when an extended resection is likely to expose the patient to the risk of liver failure. Indeed, one of the main advantages of liver segmentectomies is that they permit an economical but safe surgical resection of the hepatic parenchyma.

There is some confusion in the world literature regarding the definition of the anatomical division of the liver. Elsewhere in this symposium, the different concepts are explained and a nomenclature, that of Couinaud [1], is chosen. According to Couinaud, a segment is the smallest anatomical unit of the liver (Fig. 1). The segment described by Couinaud corresponds approximately to the subsegment described by Goldsmith and Woodburne [2]. It is different from the area described by Healey

Reprint requests: Henri Bismuth, H6pital Paul Brousse, 94800 Villejuif, France. 0364-2313/82/0006-0010 $03.00 9 1982 Socidt6 Internationale de Chirurgie

and Schroy [3], which is based upon the biliary distribution rather than upon the portal distribution. The resection of one of the 8 segments of the liver is called a segmentectomy: unisegmentectomy when 1 segment is removed, plurisegmentectomy when 2 or more segments are removed. Liver segmentectomies are intermediate procedures between the 4 common hepatectomies and the small atypical wedge resections. Segmentectomies are "r6gl6es" because they follow exclusively the anatomical liver scissurae that separate the different segments of the gland. Respect of these scissurae during segmental excisions prevents impairment of the vascularization of the remaining parenchyma and excessive bleeding. A thorough knowledge of the anatomical structure of the liver is prerequisite to the performance of liver segmentectomies. Liver segmentectomies permit the anatomical resection of hepatic lesions without the unnecessary removal of a large amount of normal parenchyma. They are particularly useful in some benign tumors or posttraumatic lesions; for carcinomas of the gallbladder; more rarely for biliary surgery above the hilus; for removal of small central hepatocarcinomas; and for liver resections in cirrhotic patients. The purpose of this report is to describe the technical aspects of the major and minor liver segmentectomies "r6gl6es." We shall also review our experience with various segmental resections in 22 patients (Table 1) who underwent this type of surgery at our hospital between 1970 and 1980. The different indications for operation are given in Table 2. Liver segmentectomies "r6gl6es" are the best illustration of the technique of primary intraparenchymatous approach of the hepatic vessels described by Ton That Tung [4]. Indeed, since most of the left or right liver is conserved, there is no place

H.Bismuth et al.: Segmentectomies in Liver Surgery

11

Table 1. Major and minor segmentectomies "rdgl6es" in

liver surgery (22 patients). Procedure Unisegmentectomies Segmentectomy IV Anterior Complete Segmentectomy VI Segmentectomy VIII Plurisegmentectomies Bisegmentectomy VI-VII Bisegmentectomy IV-V Bisegmentectomy V-VI Trisegmentectomy IV-V-VI No. of patients 7 6 1 1 1 3 6 2 2

,o,

Table 2. Indications for liver segmentectomies (22 cases).

Indication Hepatic tumors Benign Malignant Gallbladder carcinoma Liver trauma Biliary surgery Total
B Fig. 1. Segmentation of the liver according to Couinaud

No. of patients 6 6 5 3 2 22

[1]. A. Superior view. Segment VIII is visible only on this view. B. Inferior view. Segment I is visible only on this view.

which is described by Ton That Tung [4], in a patient who had a small hepatocarcinoma confined to the Spigel lobe.

Segmentectomy IV
in these techniques for an extrahepatic vascular ligation at the level of the hepatic pedicle. Usually, the liver parenchyma is approached directly along an anatomical scissura without previously dissecting the hepatic pedicle. At most, it may be useful on occasion to clamp temporarily the homolateral vessels at the hepatic pedicle or more distally, close to the liver parenchyma. Usually, only the anterior and mobile part of segment IV is removed. This anterior portion is located anteriorly to the liver hilus and corresponds to the quadrate lobe. This lobe is limited to the left by the umbilical fissure and to the right by the main scissura.

Unisegmentectomies

Anterior Segmentectomy I V or Resection of Quadrate Lobe Anterior Segmentectomy IV. Performed for the first time by Caprio [5], this technique was fully described by Champeau [6], who extended its use to biliary surgery by proposing either the mobilization or the resection of the quadrate lobe for gaining access to the superior part of the biliary confluence (Fig. 3). Through a midline or right subcostal incision, the anterior part of the falciform ligament and teres ligamentum are divided (Fig. 4). The teres ligamenturn is pulled upward and the first step of t h e

Theoretically, each of the 8 segments of the liver can be removed separately (Fig. 2). However, the elective resection of segment II or segment III has no practical value and we have no experience with it. Segmentectomy I (excision of the Spigel lobe) may be indicated in some liver tumors confined to the Spigel lobe. However, access to segment I usually requires a preliminary left lobectomy which transforms segmentectomy I into a major extended left lobectomy. We have performed this operation,

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World J. Surg. Vol. 6, No. 1, January 1982

Fig. 2. Unisegmentectomies. A and B. Segmentectomy IV: anterior, of the quadrate lobe (A), and complete (B). C. Segmentectomy VIII. D. Segmentectomy VI.

resection consists of dividing the bridge of parenchyma which frequently joins segments III and IV below the teres ligamentum. This bridge of parenchyma is transected by crushing it down with a Kelly clamp and by electrocoagulation or ligation of the small vessels. Then, the peritoneum is divided at the inferior part of the teres ligamentum and 2 or 3 arterial and portal pedicles are dissected to the right of the teres ligamentum. These pedicles are not systematized and are directed toward the quadrate lobe. The portal pedicles are behind the arterial pedicles, which are superficial. In depth, there is a fibrous tissue, which constitutes the superior limit of the teres ligamentum and in which 2 biliary ducts are usually present. On the anterior side of the liver and along the main scissura, the liver is transected up to the vertex of the hilus. There are no portal branches in this scissura and the only major vascular elements requiring ligation are the left branches of the middle hepatic vein. It is preferable to transect the liver a little to the left of the main scissura to avoid the middle hepatic vein. Posteriorly, at the inferior part of the liver, the capsule of Glisson is incised in front of the peritoneum of the hilum and some small arterial and portal branches of the quadrate lobe are ligated and divided. Subsequently, a transverse incision of the capsule of Glisson is made at the superior portion of the liver, which will join the posterior ends of the right

and left liver transections. This posterior liver transection is performed progressively by crushing down the parenchyma. During this transection, 3 to 5 branches of the middle hepatic vein are divided. Complete Segmentectomy IV. This procedure is equivalent to the complete resection of the medial part of the liver (Fig. 5). Segment IV is removed up to the anterior part of the vena cava. The first steps are similar to those performed for the resection of the quadrate lobe. However, the 2 posteriorly directed parenchymatous transections are extended up to the vena cava. The middle hepatic vein, which is usually posteriorly located close to the vena cava, is not divided during this complete segmentectomy IV. However, when the vein crosses transversely the posterior part of segment IV to join more anteriorly the left hepatic vein, it may be necessary to ligate it, without risk to the remaining parenchyma. As segment IV is just anterior to the Spigel lobe (segment I), the last step of the resection is to separate these 2 segments. There is no visible demarcation between the posterior and inferior parts of segment IV and the anterior and superior parts of segment I and, for this reason, this last step can cause bleeding. After complete resection of segment IV, the liver is almost split into 2 parts and an approximation of the 2 parts may be necessary to avoid the stomach and duodenum occupying the wide space between the right liver and the left lobe. Case Reports. Patient no. 1 was a 33-year-old female, on oral contraception for 8 years. During an operation for an ovarian cyst, she was found to have a large asymptomatic liver tumor. Angiography revealed 2 hypervascular lesions: 1 in segment IV (5 cm in diameter) and 1 in segment VIII (8 cm in diameter). At reoperation the benign nature of the tumor was established by frozen section. Because of the benign character of the lesion and the risk involved with a large resection, only the anterior lesion was removed by an anterior segmentectomy IV, principally for histological diagnosis. Definite histology was focal nodular hyperplasia. Two years later, liver ultrasound revealed no modification of the segment VIII lesion. Patient no. 2 was a 38-year-old female, on oral contraception for 8 years, who had a large asymptomatic tumor of segment IV discovered during an operation for an ovarian cyst. Angiography revealed a large hypervascular lesion in segment IV and a smaller lesion in segment VIII. At reoperation the tumor (15 cm in diameter), which was an hemangioma, was surgically removed by an anterior segmentectomy IV. The other hemangioma (7 cm in diameter) was treated by intraoperative embolization of the right paramedian artery. One year

H. Bismuth et al.: Segmentectomies in Liver Surgery

13

Fig. 3. Anterior segmentectomy IV or resection of the quadrate lobe. The different steps of the technique: (1) Opening of the umbilical fissure; (2) opening of the anterior part of the main scissura; (3) ligation of the portal pedicles entering the posterior part of the quadrate lobe; and (4) transverse transection of the parenchyma.

Fig. 4. Anterior segmentectomy IV. A. Exposure by division of the falciform ligament. B. Transection of the bridge of the parenchyma frequently found below the round ligament. C. Exposure of the vessels by opening the inferior surface of the central part of the round ligament. D. Splitting of the parenchyma along the umbilical fissure. E. Transverse transection of the parenchyma with ligation of the hepatic veins.

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World J. Surg. Vol. 6, No. 1, January 1982

II

Fig. 5. Complete segmentectomy IV.

later, liver scan revealed no modification of the remaining tumor. Patient no. 3 was a 27-year-old female who was discovered to have an enlarged liver following childbirth; angiography revealed a hypervascular lesion of segment IV (Fig. 6). At operation, a focal nodular hyperplasia (8 cm in diameter) was diagnosed by frozen section and the anterior part of segment IV was removed. Seven years later, liver scan was normal. Patient no. 4 was a 40-year-old male admitted with jaundice and hepatomegaly (Fig. 7). Liver scintiscan showed a defect at the level of the hilus. Alpha-fetoprotein was elevated. At operation, the tumor (3 cm 4 cm) was located at the posterior part of the quadrate lobe invading the anterior wall of the biliary confluence. The hepatocarcinomatous nature of the tumor was established by frozen section. As this small hepatocarcinoma was just in the middle of the quadrate lobe, equidistant from the umbilical fissure and from the main scissura, no clear choice could be made between a right extended hepatectomy and a left hepatectomy. From the

carcinological point of view, a similar tumoral excision could be done with less risk by a resection of the quadrate lobe. This was performed en bloc with the biliary confluence. The biliary reconstruction was achieved using a double bilioenteric anastomosis on a Roux-en-Y loop. Postoperative course was complicated by a wound sepsis. The patient died 3 years later from tumor recurrence. Patient no. 5, a 40-year-old male, was admitted for persistent jaundice due to a stenosis of the biliary confluence, which had been discovered at a previous operation and treated by biliary stenting. Clinical history, x-ray and histology suggested a sclerosing cholangitis. At reoperation, a resection of the quadrate lobe was performed to establish a double cholangioenteric anastomosis on the biliary ducts of segments II and V. Histology of the wall of the biliary stenosis was compatible with a sclerosing cholangitis. The postoperative course was marked by gastrointestinal bleeding 9 days after operation. One year after operation, cholestasis was markedly decreased. The patient died three years later.

H. Bismuth et al.: Segmentectomies in Liver Surgery

15

Fig. 6. Patient no. 3. Angiogram of a focal nodular hyperplasia located in the anterior part of segment IV. The tumoral arteries come from the right (rb) and left (lb) branches of the hepatic artery.

Patient no. 6, a 59-year-old male, was admitted for recurrent jaundice due to a stenosis of the biliary confluence, discovered at a previous operation and treated by biliary dilatation. Clinical history and xray suggested a sclerosing cholangitis. At operation, a resection of the quadrate lobe was performed to establish a double intrahepatic cholangioenteric anastomosis to ensure the biliary diversion of the 2 livers (Fig. 8). Histology of the wall of the biliary stenosis was compatible with a sclerosing cholangitis. The patient died 61/2 years later because of intrahepatic tumoral spread. Patient no. 7 was a 10-year-old boy, admitted complaining of fever and hepatomegaly. Liver angiography revealed a large hypervascularized mass supplied by the left and right branches of the hepatic artery, and occupying the middle part of the liver. At operation, a huge tumor (10 cm I0 cm) occupied segment IV, extending to the suprahepatic vena cava (Fig. 9). A complete segmentectomy IV was performed. This lesion was reported as hamartoma. Three years later, clinical examination and liver ultrasound were within normal limits.

gallbladder and the right extremity of the liver and ends at the level of the vena cava. During a segmentectomy VI, this transection is conducted up to the level of the hilus. At that point, the liver is transected transversely toward its right lateral side. During this transection, the anterior part of the right hepatic vein, which is superiorly located, is found and divided. Just below, the portal pedicle of segment VI is ligated and divided. Care must be taken to avoid ligation of the portal pedicle of segment VII which has a recurrent course directed toward the posterior part of the liver. Case Report. Patient no. 8 was a 49-year-old female with liver cirrhosis, admitted following an episode of intra-abdominal bleeding. Alpha-fetoprotein test results were negative and a severe liver insufficiency was detected. Angiography revealed an hypervascular lesion of segment VI compatible with a hepatocarcinoma. At operation, the excision of the tumor was performed by a segmentectomy VI. The patient had a stormy postoperative course with severe hepatic failure, jaundice, ascites, and severe disturbances of the coagulation factors. She recovered from these complications and died after 1 year from massive bleeding associated with esophageal varices. Retrospective analysis of the postoperative course suggests that a larger hepatectomy, such as a right hepatectomy, would surely have precipitated fatal postoperative hepatic failure.

Segmentectomy VIII
Segmentectomy VIII (Fig. 11) consists of the resection of the superior part of the right paramedian sector which is located at the superior and posterior part of the liver. It is connected with the intrahepatic vena cava and with segment I on the midline. These connections are complex and render the resection of segment VIII a difficult procedure. Ton That Tung [4] advocates this liver resection for the chronic liver abscesses often situated in this part of the liver. He reported having performed this segmentectomy in 10 cases. He has given a precise description of this technique. Segment VIII is limited anteriorly by a transverse line located at the level of the hilus, and posteriorly by the right coronary ligament. This segment has no base and is placed like a wedge between the right lateral scissura and the main scissura. Through a right subcostal incision, the falciform and right coronary ligaments are divided. To reduce blood loss, the hepatic pedicle can be clamped. Afterward, the right lateral and main scissurae are transected from the superior lip of the insertion of the right coronary ligament, posteriorly, up to the level of the hilus, anteriorly.

Segmentectomy VI
Segment VI (Fig. 10) is anterior to the level of the hilus and is located to the right of the right lateral scissura. Its resection alone is rarely indicated. Through a right subcostal incision, the posterior attachments of the liver are divided to permit its mobilization and exteriorization. Then, the liver parenchyma is transected along the right lateral scissura which starts at the mid point between the

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World J. Surg. Vol. 6, No. 1, January 1982

Ium scissure bilical

Fig. 7A. Patient no. 4. Operative view of a small hepatocarcinoma located in the posterior part of the quadrate lobe. B. Operative view of the excision of the quadrate lobe. The two hepatic ducts opened by the resection of the biliary confluence invaded by the carcinoma are clearly visible.

Fig. 8. Patient no. 6. Anterior resection of segment IV for the performance of a double intrahepatic cholangioenteric anastomosis.

H.

Bismuthet al.: Segmentectomiesin LiverSurgery

17

Fig. 9. Patient no. 7. Complete segmentectomy IV for a huge hamartoma occupying the middle part of the liver. The aperture is limited on the left by the umbilical fissure and on the right by the main portal scissura. The tumor came close to the inferior vena cava which is partially exposed.

~b
!~:~:~::::::~: i::::~:~

Fig. 10. Segmentectomy VI.

Fig. 11. Segmentectomy VIII.

These 2 lateral planes of cleavage are joined by 2 transverse transections along the superior lip of the insertion of the coronary ligament, posteriorly, and along the posterior part of the hilus, anteriorly. Along these lines of transection, the parenchyma is crushed and divided. During the posterior transection, the hepatic veins of segment VIII are divided. The first one goes to the middle hepatic vein and it is posteriorly located to the left, close to the posterior triangle of insertion of the falciform ligament. The second one goes to the right hepatic vein and is posteriorly located to the right. Care must be taken to confine the liver resection between the right and the middle hepatic veins. Segment VIII is then lifted upward, using stay sutures to allow the palpation and division of the vertical portal pedicles. If the portal pedicles of segment I are located too posteriorly, it may be necessary

to divide them to approach the pedicles of segment VIII.

Case Report. Patient no. 9, a 40-year-old female, was admitted with persistent intraperitoneal bleeding 2 days after a liver trauma for which she had already been operated on in another hospital. Angiography revealed an extravasation of the contrast medium at the level of segment VIII. At operation, disruption of the upper part of the liver and necrosis of the superior part of the right liver were found. Resection of the necrotic parenchyma ended in a segmentectomy VIII which, however, was not "rdglde" along all the lines of the transection. Postoperative course was complicated by an external biliary fistula and by a subphrenic abscess. Eight years after operation, the patient is alive and well.

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World J. Surg. Vol. 6, No. 1, January 1982

l
Fig. 12. Plurisegmentectomies. A. Bisegmentectomy VI-VII. B. Bisegmentectomy IV-V. C. Bisegmentectomy V-VI. D. Trisegmentectomy IV-V-VI.

Plurisegmentectomies

Right Lateral Sectoriectomy, Right Posterior Sectoriectomy or Bisegmentectomy V1-VII

The line of transection for this liver resection is the right portal scissura (Figs. 12 and 13). The difficulty of this procedure is in determining the exact location of the right portal scissura, because there is no visible demarcation between the right lateral and the right paramedian sectors of the liver. If the right portal scissura is not properly determined, the danger is in potential damage to the right hepatic vein. According to Ton That Tung [4], this scissura goes parallel to the right side of the liver about 3 fingers' breadths from it, on a plane inclined 40-45 ~ from the horizontal plane. The posterior limit of the scissura is the right side of the vena cava. The anterior limit of the right scissura is the middle of the distance between the gallbladder and the right angle of the liver. During the right lateral sectoriectomy, the only important pedicle to locate is the right lateral portal pedicle, which is posterior to the level of the hilus. Through a long right subcostal incision, the right liver is mobilized from its posterior attachments up to the vena cava. The capsule of Glisson is divided from the middle of the distance between the gallbladder and the right angle of the liver, anteriorly. At the anterior surface, the incision follows the superior lip of the right coronary ligament, 2 cm from it. At the inferior part of the liver, the incision

of the capsule of Glisson goes from the anterior side of the liver to the right end of the hilar transverse fissure. Then, the liver is transected up to the large posterior and lateral portal pedicle which is divided. Posteriorly, the right branches of the right hepatic vein are ligated and divided and the transection of the liver is continued up to the right side of the vena cava. During this transection, the right hepatic vein remains to the left and is not exposed. We have performed this operation 3 times. However, in 2 patients it was not exactly a bisegmentectomy "r6g16e." These 2 patients had sustained liver trauma which involved the posterior part of the right liver. The transection followed the right lateral scissura but also, in some places, the line of parenchymatous rupture. Case Reports. Patient no. 10, a 22-year-old male, was operated on for intraperitoneal bleeding following a traffic accident. The source of bleeding was the liver. Hemostasis was obtained by ligation of the proper hepatic artery. The patient was reoperated on for posttraumatic liver necrosis. At reoperation, the rupture of the liver followed partially the right scissura and there was a necrosis of the right lateral sector. Segments VI and VII were resected. The postoperative course was marked by a minimal external biliary fistula. Patient no. 11 was a 37-year-old male admitted with right upper quadrant pain. Scanner and echography detected a retrohepatic mass. Angiography revealed an hypervascularized lesion located in the right lateral sector of the liver and in the right

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19

Fig. 13. Right lateral sectoriectomy: Bisegrnentectomy VI-VII. Fig. 14. Bisegrnentectorny IV-V. The different steps of the technique: (1) Opening of the umbilical fissure; (2) splitting of the parenchyma to the right of teres ligamenturn; (3) opening of the right portal scissura; and (4) ligation of the portal pedicles of the quadrate lobe and of the anterior portal pedicle of the right paramedian sector.

adrenal gland. At operation, a large malignant tumor (10 cm 10 cm) of the right adrenal gland was found which invaded the right lateral sector of the liver. To excise the tumor, a right lateral sectoriectomy was performed en bloc with the resection of the right adrenal gland and kidney. Two years later, the patient is well without tumor recurrence. Patient no. 12, a 15-year-old girl, was admitted following a traffic accident, lntraperitoneal bleeding led to a laparotomy at which a posterior rupture of the right liver was found. Hemostasis was obtained by gauze compression. The patient was transferred to our department where angiography revealed an arterioportal fistula between the right lateral artery and a portal branch. At operation, a right lateral sectoriectomy was performed completing the liver rupture. The postoperative course was unremarkable. Four years after operation, the patient has a normal life.

Bisegmentectomy IV-V
This operation (Fig. 14) has an elective indication, which is cancer of the gallbladder. Indeed, the gallbladder is located at the level of the main scissura of the liver and a typical resection of the

contiguous hepatic parenchyma requires the resection of segments IV and V. An extended right hepatectomy--which is necessary when the tumor occupies a large part of the right liver--is, in our opinion [7], disproportionate when the cancer remains confined to the gallbladder bed or when it is discovered histologically following cholecystectomy for gallstones. The main technical step in bisegmentectomy I V V is the ligation of the portal pedicle of segments IV and V. The ligation must be done without impairing the vascularization of the right liver and of the left lobe. The operation is performed through a right subcostal incision. The teres ligamentum and the falciform ligament are divided. The first step of the resection is the ligation of the portal pedicles of segment IV on the right part of teres ligamentum, as described for segmentectomy IV. The second step is the left parenchymatous transection which is conducted along the umbilical

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fissure. The third step is the right liver transection, which is conducted following a line parallel to the right lateral scissura 2 cm on its right. At the inferior part of the liver, this transection is directed toward the right portal pedicle. During this transection, the large inferior and posterior right paramedian portal pedicle is found and its anterior branch is ligated. The fourth step is the ligation of the portal branches on the posterior part of the quadrate lobe. The fifth step is the posterior parenchymatous transection which joins the left and right transections in front of the hilus. During this transverse transection, the large middle hepatic vein is ligated and divided.

Case Reports. Patient no. 13, a 42-year-old male, was admitted with right upper quadrant pain. A1pha-fetoprotein levels were elevated and angiography revealed a small hypervascular lesion (5 cm in diameter) in segment IV. At operation, a small, well-circumscribed hepatocarcinoma was located in segment IV, close to segment V. The left lobe of the liver was small. Segments IV and V were resected. The postoperative course was unremarkable and the patient is alive and well 2 years after operation. Patient no. 14 was a 39-year-old female operated on for gallstones. Histological examination of the gallbladder revealed a carcinoma of the gallbladder invading the adventitia. The patient was reoperated on at our hospital and a resection of segments IV and V was performed. Histological examination of these 2 segments revealed no sign of malignancy. Two years after operation, the patient is alive and well. Biological and morphologic examinations of the liver are normal. Patient no. 15, a 57-year-old male, was operated on for gallstones. Intraoperatively, a carcinoma of the gallbladder, which extended beyond the serosa, was discovered. This patient was treated by cholecystectomy and then transferred to our department. Angiography revealed some irregularities of the branches of the right hepatic artery. The patient was reoperated on and a segmentectomy IV-V was performed. Histologically, there was some residual tumoral tissue in the gallbladder bed. The postoperative course was uncomplicated. Two years after operation, the patient died with a tumor recurrence invading the duodenum. Patient no. 16, a 29-year-old female, was operated on for right upper quadrant pain associated with an absence of opacification of the gallbladder. At operation, a carcinoma of the gallbladder, invading the gallbladder bed, was found and a cholecystectomy was performed. Postoperatively, the patient was transferred to our department. The patient was reoperated on and a bisegmentectomy IV-V was performed. Histology revealed a tumoral extension limited to the gallbladder bed. The postoperative

course was uncomplicated and the patient is alive and well after 2 years. Recently, a second-look operation was performed which did not disclose any tumoral recurrence. Patient no. 17, a 60-year-old female, underwent a cholecystectomy for gallstones. Histology of the gallbladder revealed a carcinoma confined to the gallbladder. For this reason, the patient was transferred to our department. Angiography of the liver was normal. The patient was reoperated on and a bisegmentectomy IV-V was performed. Histology revealed no sign of tumoral extension in the 2 resected segments. The postoperative course was uncomplicated and the patient is alive and well 2 years after operation. Patient no. 18, a 71-year-old male, was admitted to our department for right upper quadrant pain. Liver scintiscan revealed a defect in the right liver. Angiography showed an hypervascular lesion located at the level of the gallbladder bed. At operation, the mass was removed by performing a bisegmentectomy IV-V. Histology revealed a small carcinoma of the gallbladder penetrating into the liver. The postoperative course was uncomplicated and the patient is alive and well 10 months after operation, with no sign of tumor recurrence.

Bisegmentectomy V-VI
Proposed by Mancuso et al. [8], this bisegmentectomy is rarely performed (Fig. 15). Just as in resection of the quadrate lobe, a cholecystectomy is performed and the liver is transected along the main scissura. Contrary to what is done during the resection of the quadrate lobe, the incision of the capsule of Glisson should be slightly displaced to the right of the main scissura to avoid the middle hepatic vein during the transection. The transection is conducted up to the level of the hilus, and then the liver is transected transversely toward its right lateral side. This transection is no different from that described for bisegmentectomy IV-V and for segmentectomy VI. Case Reports. Patient no. 19 was a 2-year-old female admitted to our department with hepatomegaly. Angiography revealed a huge hypervascular tumor of the right liver. The lesion, which was a capsulated hamartoma, was resected by performing a bisegmentectomy V-VI. The postoperative course was uneventful and the patient is alive and well 4 years later. Patient no. 20, a 58-year-old male, was admitted for right upper quadrant pain and hepatomegaly. Angiography revealed an hypervascularized lesion located inside the right part of the liver. At operation, the liver was cirrhotic and the tumor proved to

H. Bismuth et al.: Segmentectomies in Liver Surgery

21

J.

Ulii!Iii" "',

Fig. 15. Bisegmentectomy V-VI.

be an hepatocarcinoma developed on the anterior edge of the right liver. This hepatocarcinoma was resected by performing a bisegmentectomy V-VI. The postoperative course was uncomplicated and the patient is alive and receiving chemotherapy with no sign of recurrence 6 months postoperatively.

Case Reports. Patient no. 21, a 29-year-old female

on oral contraception for 8 years, was admitted to our department with a huge mass located in the right upper quadrant. Angiography revealed an hypervascular lesion occupying segments IV, V, and VI and vascularized by the right and left hepatic arteries. Frozen section at operation proved the tumor to be an adenoma. The left lobe of the liver was atrophied. Because of the risk of an extended right hepatectomy for a benign tumor, an intraopex'ative embolization of the right branch of the hepatic artery was performed to reduce the size of the tumor. A few months later, the mass had shrunk. The patient was reoperated on and a trisegmentectomy IV, V, VI was performed. The postoperative course was uneventful and the patient is alive and well 2 years after operation. Patient no. 22 (Fig. 17) was a 65-year-old man admitted to our department with hepatomegaly. Alpha-fetoprotein levels were markedly increased and angiography revealed an hypervascularized mass occupying segments IV, V, and VI. Because of the presence of neoplastic lymph nodes in the porta hepatis, a palliative resection of segments IV, V, and VI was performed. This resection required no transfusion and the postoperative course was uncomplicated. A treatment regimen of chemo-

Trisegmentectomy IV-V-VI
Described by Ton That Tung [4] as an extended medial hepatectomy, the resection of segments IV, V, and VI was proposed by Couinaud [1] for treatment of carcinoma of the gallbladder because the cystic veins are likely to end in the portal branch of segment VI (Fig. 16). The first step of this trisegmentectomy is the same as for the resection of the quadrate lobe: division of the portal pedicles of segment IV on the right part of the umbilical fissure. Then, the liver is transected along the umbilical fissure up to the level of the hilus. Afterward, the capsule of Glisson is incised transversely toward the right side of the liver and, from this side, a long transverse transection is performed which leads to division of the portal pedicles of segments V and VI, of the origin of the right hepatic vein and of that of the middle hepatic vein.

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World J. Surg. Vol. 6, No. 1, January 1982

Fig. 16. Trisegmentectomy IV-V-VI.

therapy and immunotherapy was started. Nine months after operation, echography revealed a recurrent tumor in the liver. At reoperation, there were diffuse neoplastic nodules in the left lobe and in the remaining right liver. A ligation of the hepatic artery was performed. The patient is still alive and well 2 years after the first operation.
Discussion

Right and left hepatectomies and right and left lobectomies are the 4 most commonly performed liver resections. Segmental resections of the liver are rarely performed. Apart from Ton That Tung [4], who has the largest experience with this type of liver resection, only a few cases have been published. From almost 100 liver resections performed in our experience, we report herein 22 cases of segmental liver resections. Intra- and postoperative mortality was nil. In 4 patients, minor postoperative complications occurred which did not require reoperation. In a patient with cirrhosis, postoperative

hepatic insufficiency was observed following segmentectomy VI. Segmental resections of the liver are based upon a precise knowledge of the anatomical organization of the liver and especially of the distribution of the portal pedicles and hepatic veins which allowed Couinaud [1] to individualize 8 functional units in the liver: the segments are also called "subsegmerits" by Ton That Tung [4] and by Goldsmith and Woodburne [2]. From the technical point of view, segmental liver resections require a primary transparenchymatous approach as advocated by Ton That Tung [4]. For most of them, the resection is easy to perform and, providing that the anatomical rules are respected, no more difficult than the usual hepatectomies. Right posterolateral sectoriectomy and complete segmentectomy IV are more difficult to perform because of the difficulty in finding the line of cleavage for the former and to the 3 large planes of parenchymatous transection required by the latter. The main justification for choosing, in some cases, a segmental liver resection rather than one of the 4 common hepatectomies is the lesser amount of normal parenchyma excised, thus minimizing the degree of postoperative hepatic insufficiency. The minimal amount of functional liver to sustain life is still ill-defined. We believe that the risk of fatal postoperative liver failure following fiver resection is greatest when the remaining functional liver is small or cirrhotic. The risk of postoperative hepatic failure following a right extended hepatectomy is a subject of much discussion. Starzl [9] had only 1 case of fatal postoperative hepatic insufficiency in his series of 30 right extended hepatectomies but, in this case, there was a necrosis of the remaining left lobe due to vascular thrombosis. In another case, a severe postoperative hepatic insufficiency with ascites was observed [10]. Beattie [I 1] reported 1 case of postoperative hepatic failure and stated that the left lobe only is insufficient to support life. In our series of 12 right extended hepatectomies 1 patient, whose left lobe was smaller than normal, had such a dramatic course. In explaining these differences, the volume of the remaining liver is, in our opinion, the determining factor. Usually, tumors of the right liver, which are the indications for an extended right hepatectomy, are large tumors which destroy a large part of the right lobe. A concomitant hypertrophy of the left lobe is usually present. In some cases, however, the left lobe retains its normal size, that is to say, 10-15% of the liver [12] or is smaller because of constitutional atrophy. We think that, in this latter event, a right extended hepatectomy carries a risk of fatal postoperative hepatic failure; the frequency is, however, difficult to state.

H. Bismuth et al.: Segmentectomies in Liver Surgery

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Fig. 17. Patient no. 22. A. Excision of an hepatocarcinoma at the anterior edge of the right lobe by a trisegmentectomy IVV-VI. B. View of the specimen.

The second circumstance in which a cautious attitude concerning the resection of the functional parenchyma is advisable is met in cirrhotic patients. The risk of postoperative hepatic failure is particularly high when cirrhosis is severe (B or C grade, according to Child's classification) or when a large amount of cirrhotic parenchyma has to be removed with the tumor. In our series of liver resections in cirrhotic patients, a right hepatectomy was performed for a tumor developed at the anterior edge of the right liver. Because of the superficial location of the tumor, this resection removed a large amount of nontumoral cirrhotic parenchyma. The patient died alter 10 days from progressive hepatic failure. These 2 restrictions to major hepatectomies are, in our opinion, a motivation to c h o o s e - - i n some c a s e s - - a less extensive surgery, that is to say, a segmental resection. When the benign nature of a solid liver tumor is affirmed intraoperatively by frozen section, there is

no reason for an extensive resection of the normal surrounding parenchyma. If segmental resection would appear easily and safely performed in the given case, it is reasonable to choose this type of resection rather than a larger c o m m o n hepatectomy. As regards trauma of the liver, the frequent location of the rupture at the posterior part of the right liver is a good indication for a posterolateral right sectoriectomy such as we did in 2 cases. A particular indication for the resection of the quadrate lobe can be met in the field of biliary surgery: to gain access to the upper part of the biliary confluence [6] or to perform an intrahepatic cholangioenteric anastomosis [13]. Segmental resections in malignant tumors are indicated in some particular conditions. In a series of 38 patients who underwent liver resection for hepatocarcinomas, we performed 5 segmental resections. In 2 cases, the procedure was performed because of associated cirrhosis, in 2 other cases,

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World J. Surg. Vol. 6, No. 1, January 1982

the hepatocarcinoma was small and located in the quadrate lobe, equidistant from the main scissura and the umbilical fissure. F r o m the carcinological point of view, a right extended hepatectomy or a left hepatectomy has no advantage when compared to a segmentectomy IV which follows the same scissurae. In the last case, the resection was palliative. Another indication for segmental liver resection is carcinoma of the gallbladder when malignancy is discovered by histological examination of a gallbladder specimen removed for gallstones. If histology reveals that the carcinoma has extended beyond the wall of the gallbladder, we think that there is an indication for a complementary liver resection. This resection should remove the contiguous liver parenchyma: segments IV and V. The right extended hepatectomy, which is often proposed, is in our opinion disproportionate [7] since it removes an almost entirely normal right lobe. Three of our patients operated on by a bisegmentectomy I V - V after histological discovery of a carcinoma of the gallbladder are presently alive after more than 2 years with no sign of tumor recurrence. In conclusion, major and minor hepatic segmentectomies "rdgldes" are one of the best illustrations of the anatomical surgery of the liver. They are not techniques " d e facilit6" which can be chosen for a rapid and expeditious surgery. They are interesting alternatives to the c o m m o n hepatectomies when a more economical resection is permitted by the location and the nature of the lesion, or when a major hepatectomy is likely to expose the patient to the risk of postoperative hepatic failure.

foie, (3) la chirurgie biliaire sus-hilaire oil une rdsection de la partie ant6rieure du segment IV peut ~tre ndcessaire, et (4) le cancer vdsiculaire lors qu'il a ~t~ ddcouvert sur une pi6ce de cholecystectomie. Les segmentectomies h6patiques peuvent fitre indiqu6es 6galement dans certaines tumeurs malignes lorsque le foie est cirrhotique ou lorsqu'une ex6r6se 61argie fait courir un risque d'insuffisance h6patique. L ' u n des avantages principaux des rdsections segmentaires du foie est en effet de permettre une exdr~se 6conomique du parenchyme hdpatique.

References 1. Couinaud, C.: Le Foie. Etudes Anatomiques et Chirurgicales. Paris, Masson, 1957 2. Goldsmith, N.A., Woodburne, R.T.: The surgical anatomy pertaining to liver resection. Surg. Gynecol. Obstet. 195:310, 1957 3. Healey, J.E., Schroy, P.C.: Anatomy of the biliary ducts within the human liver. Arch. Surg. 66:599, 1953 4. Ton That Tung: Les Rdsections Majeures et Mineures du Foie. Paris, Masson, 1979 5. Caprio, G.: Un caso de extirpacion del Iobulo izquierdo del higado. Bull. Soc. Cir. Urug. Montevideo 2:159, 1931 6. Champeau, M., Pineau, P.: Voie d'abord 61argie trans-hdpatique du canal hdpatique gauche. Mere. Acad. Chir. 90:602, 1964 7. Bismuth, H., Malt, R.: Carcinoma of the biliary tract. N. Engl. J. Med. 301:704, 1979 8. Mancuso, M., Natalini, E., Del Grande, G.: Contributo alla conoscenza della struttura segmentaria del fegato in rapporto al problema della resezione epatica. Policlinico. Sez. Chir. 72:1955 9. Starzl, T.E., Koep, L.J., Weill, R., III, Lilly, J.R., Putnam, C.W., Aldrete, J.A.: Right trisegmentectomy for hepatic neoplasms. Surg. Gynecol. Obstet. 150:208, 1980 10. Starzl, T.E., Putnam, C.W., Groth, C.G., Corman, J.L., Taubman, J.: Alopecia, ascites, and incomplete regeneration after 85 to 90 per cent liver resection. Am. J. Surg. 129:587, 1975 11. Beattie, E.G.: Discussion in McBride, C.M., Wallace, C.: Cancer of the right lobe of the liver. A variety of operative procedures. Arch. Surg. 105:289, 1972 12. Stone, H.H., Long, W.D., Smith, R.B., Haynes, C.D.: Physiological considerations in major hepatic resections. Am. J. Surg. 117:78, 1969 13. Bismuth, H., Corlette, M.B.: Intra-hepatic cholangio-enteric anastomosis in carcinoma of the hilus of the liver. Surg. Gynecol. Obstet. 140:170, 1975

R~sum~ L'individualisation du segment comme unit6 anatomique fonctionnelle h6patique permet la r6alisation de segmentectomies. Elles sont rdgldes parce que les plans de section du p a r e n c h y m e h~patique suivent des scissures anatomiques. Du point de vue technique, les segmentectomies h6patiques se caractdrisent par un abord transparenchymateux exclusif des pddicules vasculaires. Nous avons rdalis6 ce type d'intervention chez 22 malades sans mortalit6. Les indications principales sont: (1) quelques tumeurs bdnignes, (2) certains traumatismes du