In the patient described above, which of the following are impoant operative steps in the performance of a right hepatic lobectomy?
The steps involved in a right hepatic lobectomy involve adherence to the tenet of optimal operative exposure and control of vascular inflow and outflow. In select circumstances, control of the vena cava may be desired. Either the individual poal structures can be identified and ligated early in the course of the procedure, or simply the entire poal triad can be circled with an umbilical tape tourniquet in preparation for the Pringle maneuver. If temporary poal inflow occlusion is used, intermittent 10 to 20 minute intervals of clamping with 3 to 5 minutes to reestablish blood flow is recommended. The division of the hepatic parenchyma begins with scoring of Glisson's capsule with cautery or knife and proceeds with division of the hepatic surface using either blunt dissection by finger fracture, the blunt edge of an instrument or suction tip, or using an ultrasonic dissector. Individual vessels and bile ducts are cauterized, sutured, or clipped in rapid succession from anterior to posterior. The hepatic veins are encountered in the hepatic substance near the vena cava and are carefully clamped and suture ligated to complete the resection. In addition, there are also several posterior accessory veins (up to 10 in number) which drain the medial aspect of the right lobe and empty directly into the right anterior surface of the IVC.
The use of an ultrasonic dissector is essential for division of the hepatic parenchyma
If temporary poal inflow occlusion is used (Pringle maneuver), it is not necessary to reestablish blood flow during the course of the parenchymal division
The greater omentum may be used to buttress the transected liver edge
Control of the main right hepatic vein should eliminate all forms of venous drainage
Liver