Abstract

• An extrahepatic approach to vascular structures, combined with an intra-parenchymal left bile duct division, is the preferred technique to perform leftliver resection. IOUS is an indispensable resource – not only to confirm selective vascular disconnection, but also to identify the appropriate transection planeduring parenchyma transection.

• The left hepatic vascular pedicle is perpendicular in relation to the right pedicle when the round ligament is held upward during left hepatectomy.

• The transection plane of a left hepatectomy is initially vertical until the hilar plate, and becomes horizontal following the Arantius plane after the bile ductsection.

• A hanging maneuver is also a useful technique for left resection extended to segment 1 or to the middle hepatic vein, since the transection plane is the same as that for a right hepatectomy.

• Total vascular exclusion should be performed in case of voluminous tumors that are in close proximity to hepatic veins.

• Vascular control of the left middle hepatic trunk is achieved from the left to the right in a strict horizontal plane. Lowering segment 1 and cutting the Arantius ligament are mandatory in order to safely perform this vascular control.