Left hepatectomy or left trisectionectomy with resection of the caudate lobe and extrahepatic bile duct for hilar cholangiocarcinoma (with video).

PURPOSE: Although left-sided hepatectomy, such as a left hepatectomy or left trisectionectomy with resection of the caudate lobe and extrahepatic bile duct, is used to treat hilar cholangiocarcinoma predominantly involving the left side of the hepatic hilum, it is associated with several difficult technical points. The important points during left-sided hepatectomy are described here. TECHNIQUES: There are anatomical variations of the sectional artery and bile duct. It is essential to understand the individual intrahepatic and hilar anatomy preoperatively. Surgical procedures consist of lymph node clearance, dissection of the distal bile duct, skeletonization resection of the hepatoduodenal ligament, mobilization of the liver and liver resection, dissection of the intrahepatic bile ducts, and biliary reconstruction. During lymph node dissection and skeletonization resection of the hepatoduodenal ligament, the nerve plexus around the hepatic artery is dissected, and its adventitia is exposed with great care to avoid injuring the hepatic artery. Mobilization of the caudate lobe is performed only from the left side. There is no clear landmark between the caudate lobe and the right posterior section during liver resection. In the final step of liver resection, it progresses toward the right edge of the inferior vena cava. When dividing intrahepatic bile ducts, extreme care should be used to avoid injury to the corresponding hepatic arteries, especially the anomalous supraportal posterior sectional artery.
CONCLUSIONS: Left-sided hepatectomy for hilar cholangiocarcinoma should be considered a more complicated and technically demanding procedure than right-sided hepatectomy. Surgeons need to pay close attention to anatomical variations in order to perform a left-sided hepatectomy safely and successfully.