Right intersectional transection plane based on portal inflow in left trisectionectomy

  • Isamu Hosokawa
  • Masayuki Ohtsuka
  • Hideyuki Yoshitomi
  • Katsunori Furukawa
  • Masaru Miyazaki
  • Hiroaki ShimizuEmail author
Original Article



Left trisectionectomy (LT) extending to the segment I with bile duct resection for perihilar cholangiocarcinoma (PHC) is a technically demanding procedure with high morbidity. Liver transection during LT is generally conducted to expose the right hepatic vein (RHV) on the remnant side. In clinical practice, we have often encountered a discrepancy between the theoretical RHV-oriented plane and the actual right intersectional plane.


To enable anatomical LT safely, the three-dimensional right intersectional transection plane based on portal inflow was investigated using multidetector-row computed tomography, and it was compared to the theoretical RHV-oriented plane in 100 patients with hepatobiliary disease.


The posterior portion of RHV just below the diaphragm was supplied by the dorsal portal branches of segment VIII in 85 cases of 100 (85.0%). The median volume of this portion was 82 mL (25–169 mL). On the other hand, the anterior region of the peripheral RHV was supplied by a few small ventral portal branches of segment VI in 24 of 90 cases (26.7%). The median volume of this portion was 53 mL (20–104 mL). In ten cases with a large inferior RHV, the RHV trunk was relatively short and did not reach the caudal part of the liver.


The portal inflow-oriented right intersectional plane does not coincide with the RHV-oriented plane in most cases. The cranial part of the actual transection plane becomes hollow, whereas the caudal part is protruded in relation to the RHV. Hepatobiliary surgeons should recognize this complicated transection plane to avoid postoperative complications when performing LT for PHC.


Right intersectional plane Left trisectionectomy Perihilar cholangiocarcinoma 


Author contributions

IH: data collection or management and manuscript writing/editing; MO: data analysis; HY: data collection or management; KF: data collection or management; MM: data analysis; HS: protocol/project development and manuscript writing/editing. All authors read and approved the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.


  1. 1.
    Bismuth H (1982) Surgical anatomy and anatomical surgery of the liver. World J Surg 6:3–9CrossRefGoogle Scholar
  2. 2.
    Bismuth H (1988) Surgical anatomy and anatomical surgery of the liver. In: Blumgart LH (ed) Surgery of the liver and biliary tract. Churchill Livingstone, Edinburgh, pp 3–9Google Scholar
  3. 3.
    Couinaud C (1953) Etude de la veine porte intra-hepatique. Press Med 61:1434–1438PubMedGoogle Scholar
  4. 4.
    Couinaud C (1986) Surgical anatomy of the liver. Several new aspects. Chirurgie 112:337–342PubMedGoogle Scholar
  5. 5.
    Esaki M, Shimada K, Nara S et al (2013) Left hepatic trisectionectomy for advanced perihilar cholangiocarcinoma. Br J Surg 100:801–807CrossRefGoogle Scholar
  6. 6.
    Farid SG, White A, Khan N et al (2016) Clinical outcomes of left hepatic trisectionectomy for hepatobiliary malignancy. Br J Surg 103:249–256CrossRefGoogle Scholar
  7. 7.
    Hochwald SN, Burke EC, Jarnagin WR et al (1999) Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma. Arch Surg 134:261–266CrossRefGoogle Scholar
  8. 8.
    Hosokawa I, Shimizu H, Yoshidome H et al (2014) Surgical strategy for hilar cholangiocarcinoma of the left-side predominance: current role of left trisectionectomy. Ann Surg 259:1178–1185CrossRefGoogle Scholar
  9. 9.
    Hosokawa I, Shimizu H, Yoshidome H et al (2014) Left hepatic trisectionectomy for hepatolithiasis with occluded left and right anterior branches of the portal vein: report of a case. Surg Today 44:1556–1560CrossRefGoogle Scholar
  10. 10.
    Hosokawa I, Shimizu H, Yoshitomi H et al (2018) Outcomes of left trisectionectomy and right hepatectomy for perihilar cholangiocarcinoma. HPB. CrossRefPubMedGoogle Scholar
  11. 11.
    Hosokawa I, Shimizu H, Yoshitomi H et al (2018) Impact of biliary drainage on multidetector-row computed tomography on R0 resection of perihilar cholangiocarcinoma. World J Surg 42:3676–3684CrossRefGoogle Scholar
  12. 12.
    Kenjo A, Miyata H, Gotoh M et al (2014) Risk stratification of 7,732 hepatectomy cases in 2011 from the National Clinical Database for Japan. J Am Coll Surg 218:412–422CrossRefGoogle Scholar
  13. 13.
    Lee MK IV, Gao F, Strasberg SM (2015) Perceived complexity of various liver resections: results of 30 a survey of experts with development of a complexity score and classification. J Am Coll Surg 220:64–69CrossRefGoogle Scholar
  14. 14.
    Maurer R, Rivoire M, Basso V et al (2017) Portal supply of segment IV of the liver based on CT-scan. Surg Radiol Anat 39:471–476CrossRefGoogle Scholar
  15. 15.
    Morel A, Rivoire M, Basso V et al (2017) Identification of intra-hepatic communicating veins through the arch sign on CT-scan. Surg Radiol Anat 39:673–677CrossRefGoogle Scholar
  16. 16.
    Nagino M, Ebata T, Yokoyama Y et al (2013) Evolution of surgical treatment for perihilar cholangiocarcinoma: a single-center 34-year review of 574 consecutive resections. Ann Surg 258:129–140CrossRefGoogle Scholar
  17. 17.
    Natsume S, Ebata T, Yokoyama Y et al (2012) Clinical significance of left trisectionectomy for perihilar cholangiocarcinoma: an appraisal and comparison with left hepatectomy. Ann Surg 255:754–762CrossRefGoogle Scholar
  18. 18.
    Nishio H, Hidalgo E, Hamady ZZ et al (2005) Hepatic trisectionectomy for hepatobiliary malignancy: results and an appraisal of its current role. Ann Surg 242:267–275CrossRefGoogle Scholar
  19. 19.
    Nomura T, Shirai Y, Hatakeyama K (1999) Bacteribilia and cholangitis after percutaneous transhepatic biliary drainage for malignant biliary obstruction. Dig Dis Sci 44:542–546CrossRefGoogle Scholar
  20. 20.
    Sakata J, Shirai Y, Tsuchiya Y et al (2009) Preoperative cholangitis independently increases in-hospital mortality after combined major hepatic and bile duct resection for hilar cholangiocarcinoma. Langenbecks Arch Surg 394:1065–1072CrossRefGoogle Scholar
  21. 21.
    Sato F, Igami T, Ebata T et al (2014) A study of the right intersectional plane (right portal scissura) of the liver based on virtual left hepatic trisectionectomy. World J Surg 38:3181–3185CrossRefGoogle Scholar
  22. 22.
    Shimizu H, Hosokawa I, Ohtsuka M et al (2014) Clinical significance of anatomical variant of the left hepatic artery for perihilar cholangiocarcinoma applied to right-sided hepatectomy. World J Surg 38:3210–3214CrossRefGoogle Scholar
  23. 23.
    Shindoh J, Mise Y, Satou S et al (2010) The intersegmental plane of the liver is not always flat–tricks for anatomical liver resection. Ann Surg 251:917–922CrossRefGoogle Scholar
  24. 24.
    Strasberg SM (2005) Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. J Hepatobiliary Pancreat Surg 12:351–355CrossRefGoogle Scholar
  25. 25.
    Suda K, Ohtsuka M, Ambiru S et al (2009) Risk factors of liver dysfunction after extended hepatic resection in biliary tract malignancies. Am J Surg 197:752–758CrossRefGoogle Scholar
  26. 26.
    Uesaka K (2012) Left hepatectomy or left trisectionectomy with resection of the caudate lobe and extrahepatic bile duct for hilar cholangiocarcinoma. J Hepatobiliary Pancreat Sci 19:195–202CrossRefGoogle Scholar
  27. 27.
    van Leeuwen MS, Noordzij J, Fernandez MA et al (1994) Portal venous and segmental anatomy of the right hemiliver: observations based on the three-dementional spiral CT renderings. AJR 163:1395–1404CrossRefGoogle Scholar
  28. 28.
    Watanabe Y, Kuboki S, Shimizu H et al (2018) A new proposal of criteria for the future remnant liver volume in older patients undergoing major hepatectomy for biliary tract cancer. Ann Surg 267:338–345CrossRefGoogle Scholar
  29. 29.
    Yasaka K, Akai H, Kiryu S (2017) Anomalous branching pattern of the portal vein: right posterior portal vein originating from the left portal vein. Surg Radiol Anat 39:573–576CrossRefGoogle Scholar
  30. 30.
    Young AL, Prasad KR, Toogood GJ et al (2010) Surgical treatment of hilar cholangiocarcinoma in a new era: comparison among leading Eastern and Western centers, Leeds. J Hepatobiliary Pancreat Sci 17:497–504CrossRefGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of SurgeryTeikyo University Chiba Medical CenterIchiharaJapan
  2. 2.Department of General SurgeryChiba University Graduate School of MedicineChibaJapan
  3. 3.Mita HospitalInternational University of Health and WelfareTokyoJapan

Personalised recommendations