Resection of the Middle Inferior Area Couinauds S5

The feeders of this area are a few tertiary branches ramified from the middle segmental branch near the hepatic hilum (Fig. 7.32). The procedure for this resection is essentially the same as that for an S6 resection. First, the border between the left and the middle segment is identified by the clamping of the middle segmental branch. Then, the liver parenchyma is dissected along this plane to a depth of about 5 to 6 cm caudally, reaching the trunk of the middle segmental branch (Fig. 7.33a). Some tertiary branches ramifying from the middle segmental branch are ligated and cut, stepwise from the hilum to a point deep inside the liver, after having confirmed the area by clamping these tertiary branches. Liver dissection should be done on the demarcated line (Fig. 7.33b).

Fig. 7.32. The schema of Couinaud's S5 resection
Fig. 7.33a. Procedure for S5 resection

Resection of the Middle Superior Area (Couinaud's S8) (See DVD 2)

The tertiary branches of the middle segmental branch distant from the hepatic hilum nourish the middle superior area. Transection takes place at the mid-portion of the middle branch of the Glissonean pedicle (Fig. 7.34). The tertiary branches supplying this area ramify from the main trunk of the middle segmental branch deep inside the liver; therefore, the parenchymal approach is introduced.

A temporary clamp is applied to the middle segmental branch (Fig. 7.35a). The borderline of the left segment should be confirmed by the demarcation line. Dissection proceeds along this demarcated line in a direction toward the hepatic hilum; then the middle hepatic vein is seen along the incision. This middle hepatic vein is to remain intact and is to be placed along the remaining side of the cut surface. Dissection continues up to the middle segmental branch (Fig. 7.35b). The peripheral part of the middle segmental

Tertiary branches for upper part of middle segment ■

Mid-portion of middle branch of Glissonean pedicle

Fig. 7.34. Schema of resection of Couinaud's S8

branch can be cut (Fig. 7.35c). Liver dissection may be done on the demarcated line. The direction of dissection must be kept toward the cut stump of the segmental branch. After the resection of S8, there is a cone-shaped hole in the upper part of the liver. The cut stump of the segmental branch lies at the bottom of this hole and the cut stumps of the left hepatic vein and right hepatic vein lie on the cut surface of both sides of the liver parenchyma (Fig. 7.35d).

Hilus The Liver
Fig. 7.35a. Procedure for resection of Couinaud's S8. First, middle segmental branch is clamped at the hepatic hilus. Liver parenchyma is dissected on the upper side of demarcated line
Fig. 7.35b. Dissection proceeds deeply into the liver. Tertiary branch for S8 area comes into existence on right side of the middle hepatic vein

Fig. 7.35c. After transecting the tertiary branch, an area fed by this branch is demarcated c

Fig. 7.35c. After transecting the tertiary branch, an area fed by this branch is demarcated

d

Fig. 7.35d. At the cut surface of the liver are the lateral wall of the middle hepatic vein and the cut stump of the middle segmental Glissonean pedicle. Upper part of middle segment resection is completed

Fig. 7.36. This area is fed by the peripheral branch

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