Resection of the Medial Area of the Left Segment Couinauds S4

The left medial area of the left segment is fed by some tertiary branches which arise from the left part of the umbilical portion of the Glissonean pedicle (Figs. 7.18 and 7.19). The round ligament is pulled upward. Then the umbilical portion is seen en face. The upper right side of the umbilical portion of the Glissonean pedicle is torn from the surrounding liver tissue. Several tertiary branches come into view, and these must be transected one by one (Fig. 7.20a-d).

Fig. 7.18. Resection of Couinaud's S4 (left medial area of left segment)
Fig. 7.19. Schema of resection of Couinaud's S4 (left medial area of left segment)

Fig. 7.20a-d. Detachment of the right side of the surrounding liver parenchyma. There are a number of tertiary branches

Tertiary branch

Fig. 7.20a-d. Detachment of the right side of the surrounding liver parenchyma. There are a number of tertiary branches

Tertiary branch a

Umbilical portion of Glissonean pedicle (left segmental branch)
Fig. 7.20. Continued

Dissection of the border of the medial segment (Fig. 7.21) is done in just the same way as that done in left segmentectomy. After ligation of the tertiary branches which feed the medial segment, the true border will be recognized by the change of color of the parenchyma. Dissection is performed along the two demarcated planes shown in Fig. 7.22a-c. The border of the caudate area is dissected on the plane of the paracaval triangle.

Fig. 7.21. Dissection of border of medial segment
Fig. 7.22a. Dissection on left demarcated plane is performed
Middle hepatic vein

Fig. 7.22c. Medial area of the left segment resection is completed c

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