Up-to-down open and laparoscopic liver hanging maneuver: an overview



The liver hanging maneuver (LHM) was described by Belghiti et al. to facilitate liver resection and is done classically by creating a space between the caudate lobe and the inferior vena cava starting on the edge of caudate lobe and extending cranially, in a para-caval fashion, towards the space between the right and middle hepatic veins. LHM facilitates liver transection, guides anatomical resections, decreases blood loss, facilitates harvesting of the liver graft in live donors, and also has oncological advantages.

Study design

We describe a new approach named “up-to-down” to perform LHM in open and laparoscopic liver resections. This approach was mainly used in obese patients, in laparoscopic liver resections and in cases of failure of the classic approach. The advantages/disadvantages, complications, and different modalities of LHM are also summarized.


The peritoneal layer between the liver capsule and the infrahepatic vena cava is opened, and a short blind dissection is initiated on the right anterolateral aspect of the inferior vena cava to the left of the hepatic vein of segment VI. The suprahepatic vena cava is exposed, and the space between the right and middle hepatic veins and the vena cava is created by gentle dissection. A 16-Fr nasogastric tube is positioned in the space between the right and middle hepatic vein, pointing inferiorly, and pushed downwards, in a para-caval manner caudally until it is seen inferiorly. The results of this approach are given.


LHM facilitates liver resection, and many variations have been described worldwide in open and laparoscopic liver surgery. The up-to-down approach should be part of the surgical armamentarium in order to offer a safer way to achieve LHM in some patients.

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Liver hanging maneuver


IVC Inferior vena cava


  1. 1.

    Belghiti J, Guevara OA, Noun R, Saldinger PF, Kianmanesh R (2001) Liver hanging maneuver: a safe approach to right hepatectomy without liver mobilization. J Am Coll Surg 193(1):109–111

    CAS  Article  Google Scholar 

  2. 2.

    Ogata S, Belghiti J, Varma D, Sommacale D, Maeda A, Dondero F, Sauvanet A (2007) Two hundred liver hanging maneuvers for major hepatectomy: a single-center experience. Ann Surg 245(1):31–35

    Article  Google Scholar 

  3. 3.

    Liu CL, Fan ST, Cheung ST, Lo CM, Ng IO, Wong J (2006) Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma: a prospective randomized controlled study. Ann Surg 244(2):194–203

    Article  Google Scholar 

  4. 4.

    Li H, Zhu B, Huang J et al (2018) Liver hanging maneuver versus conventional approach for open hepatectomy: a meta-analysis. HPB (Oxford)

  5. 5.

    Sadamori H, Yagi T, Shinoura S, Umeda Y, Yoshida R, Satoh D, Nobuoka D, Utsumi M, Yoshida K, Fujiwara T (2013) Bloodless donor hepatectomy in living donor liver transplantation: counterclockwise liver rotation and early hanging maneuver. J Gastrointest Surg 17(1):203–206

    Article  Google Scholar 

  6. 6.

    Shindoh J, Aoki T, Hasegawa K, Beck Y, Sugawara Y, Makuuchi M, Kokudo N (2012) Donor hepatectomy using hanging maneuvers: Tokyo University experiences in 300 donors. Hepatogastroenterology. 59(118):1939–1943

    PubMed  Google Scholar 

  7. 7.

    Kim SH, Kim YK (2012) Living donor right hepatectomy using the hanging maneuver by Glisson’s approach under the upper midline incision. World J Surg 36(2):401–406

    Article  Google Scholar 

  8. 8.

    Vennarecci G, Levi Sandri GB, Ettorre GM (2016) Performing the ALPPS procedure by anterior approach and liver hanging maneuver. Ann Surg 263(1):e11

    Article  Google Scholar 

  9. 9.

    Dokmak S, Ben Safta Y, Ftériche FS, Aussilhou B, Belghiti J (2014) Pure laparoscopic right hepatectomy with the hanging maneuver for multiple hepatocellular adenomas. Ann Surg Oncol 21(12):3800–3801

    Article  Google Scholar 

  10. 10.

    Nitta H, Sasaki A, Fujita T, Itabashi H, Hoshikawa K, Takahara T, Takahashi M, Nishizuka S, Wakabayashi G (2010) Laparoscopy-assisted major liver resections employing a hanging technique: the original procedure. Ann Surg 251(3):450–453

    Article  Google Scholar 

  11. 11.

    Donadon M, Abdalla EK, Vauthey JN (2007) Liver hanging maneuver for large or recurrent right upper quadrant tumors. J Am Coll Surg 204(2):329–333

    Article  Google Scholar 

  12. 12.

    Kim SH, Park SJ, Lee SA, Lee WJ, Park JW, Hong EK, Kim CM (2007) Various liver resections using hanging maneuver by three glisson's pedicles and three hepatic veins. Ann Surg 245(2):201–205

    Article  Google Scholar 

  13. 13.

    Nanashima A, Tobinaga S, Araki M, Nonaka T, Abo T, Hidaka S, Takeshita H, Sawai T, Nagayasu T (2009) Double liver hanging manoeuvre for central hepatectomy. HPB (Oxford) 11(6):529–531

    Article  Google Scholar 

  14. 14.

    Perini MV, Coelho FF, Kruger JA, Rocha FG, Herman P (2016) Extended right hepatectomy with caudate lobe resection using the hilar “en bloc” resection technique with a modified hanging maneuver. J Surg Oncol 113(4):427–431. https://doi.org/10.1002/jso.24154

    Article  PubMed  Google Scholar 

  15. 15.

    Chowdappa R, Sagar RC, Ramesh S, Appaji L, Maneya P, Mukundapai M (2019) Central hepatectomy (mesohepatectomy) by double liver hanging maneuver (DLHM) in a child with hepatoblastoma. Indian J Surg Oncol 10(1):46–49

    Article  Google Scholar 

  16. 16.

    Kim JH, Cho BS, Jang JH (2018) Pure laparoscopic anatomical segment VI resection using the Glissonian approach, Rouviere's sulcus as a landmark, and a modified liver hanging maneuver (with video). Langenbeck's Arch Surg 403(1):131–135

    Article  Google Scholar 

  17. 17.

    Chu H, Cao G, Tang Y, Du X, Min X, Wan C (2018) Laparoscopic liver hanging maneuver through the retrohepatic tunnel on the right side of the inferior vena cava combined with a simple vascular occlusion technique for laparoscopic right hemihepatectomy. Surg Endosc 32(6):2932–2938

    Article  Google Scholar 

  18. 18.

    Liddo G, Buc E, Nagarajan G, Hidaka M, Dokmak S, Belghiti J (2009) The liver hanging manoeuvre. HPB (Oxford) 11(4):296–305

    Article  Google Scholar 

  19. 19.

    Tanaka K, Wakabayashi T (2020) Cautions concerning hanging maneuvers during hepatobiliary pancreatic surgery. Surgery. 167(2):516

    Article  Google Scholar 

  20. 20.

    Wu TJ, Wang F, Lin YS, Chan KM, Yu MC, Lee WC (2010) Right hepatectomy by the anterior method with liver hanging versus conventional approach for large hepatocellular carcinomas. Br J Surg 97(7):1070–1078

    Article  Google Scholar 

  21. 21.

    Beppu T, Imai K, Okuda K, Eguchi S, Kitahara K, Taniai N, Ueno S, Shirabe K, Ohta M, Kondo K, Nanashima A, Noritomi T, Shiraishi M, Takami Y, Okamoto K, Kikuchi K, Baba H, Fujioka H (2017) Anterior approach for right hepatectomy with hanging maneuver for hepatocellular carcinoma: a multi-institutional propensity score-matching study. J Hepatobiliary Pancreat Sci 24(3):127–136

    Article  Google Scholar 

  22. 22.

    Llado L, Muñoz A, Ramos E, Torras J, Fabregat J, Rafecas A (2016) The anterior hanging-approach improves postoperative course after right hepatectomy in patients with colorectal liver metastases. Results of a prospective study with propensity-score matching comparison. Eur J Surg Oncol 42(2):176–183

    CAS  Article  Google Scholar 

  23. 23.

    Troisi RI, Montalti R (2012) Modified hanging maneuver using the goldfinger dissector in laparoscopic right and left hepatectomy. Dig Surg 29(6):463–467

    Article  Google Scholar 

  24. 24.

    Takahashi M, Wakabayashi G, Nitta H, Takeda D, Hasegawa Y, Takahara T, Ito N (2013) Pure laparoscopic right hepatectomy by anterior approach with hanging maneuver for large intrahepatic cholangiocarcinoma. Surg Endosc 27(12):4732–4733

    Article  Google Scholar 

  25. 25.

    Casaccia M, Andorno E, Di Domenico S et al (2012) Laparoscopic right posterior sectionectomy for hepatocellular carcinoma using a modified liver-hanging maneuver. J Laparoendosc Adv Surg Tech A 22(5):488–491

    Article  Google Scholar 

  26. 26.

    Kim JH (2017) Modified liver hanging maneuver focusing on outflow control in pure laparoscopic left-sided hepatectomy. Surg Endosc 25

  27. 27.

    Rhaiem R, Piardi T, Kellil T, Cagniet A, Chetboun M, Kianmanesh R, Sommacale D (2018) The liver hanging maneuver in laparoscopic liver resection: a systematic review. Surg Today 48(1):18–24

    Article  Google Scholar 

  28. 28.

    Kim JH, Kim H (2020) Modified liver hanging maneuver in laparoscopic major hepatectomy: the learning curve and evolution of indications. Surg Endosc 34(6):2742–2748

    Article  Google Scholar 

  29. 29.

    Kim JH (2019) Three-dimensional ventral approach with the modified liver-hanging maneuver during laparoscopic right hemihepatectomy. Ann Surg Oncol 26(7):2253

    Article  Google Scholar 

  30. 30.

    Mizuguchi T, Kawamoto M, Meguro M, Okita K, Nishidate T, Furuhata T, Hui TT, Hirata K (2014) Saline injection method for facilitating the liver hanging maneuver during hepatectomy for a large right liver tumor. J Am Coll Surg 219(2):e11–e14

    Article  Google Scholar 

  31. 31.

    Chu H, Cao G, Tang Y et al (2017) Laparoscopic liver hanging maneuver through the retrohepatic tunnel on the right side of the inferior vena cava combined with a simple vascular occlusion technique for laparoscopic right hemihepatectomy. Surg Endosc

  32. 32.

    Farges O, Goutte N, Dokmak S et al (2014) For the ACHBT French hepatectomy study group. How surgical technology translates into practice: the model of laparoscopic liver resections performed in France. Ann Surg

  33. 33.

    Dokmak S, Meniconi RL, Aussilhou B (2017) Laparoscopic left hepatectomy with hanging maneuver for hepatocellular carcinoma with thrombectomy of the left portal vein (with video). J Visc Surg 154(3):213–215

    CAS  Article  Google Scholar 

  34. 34.

    Ettorre GM, Vennarecci G, Santoro R, Boschetto A, Miglioresi L, Corazza V, Mancini P, Lorusso R, Spoletini D, Antonini M, Tacconi G, Santoro E (2007) Modified liver hanging maneuver during orthotopic liver transplantation with inferior vena cava preservation: results after 120 consecutive applications. Transplant Proc 39(6):1881–1882

    CAS  Article  Google Scholar 

  35. 35.

    Pessaux P, Rosso E, Panaro F, Marzano E, Oussoultzoglou E, Bachellier P, Jaeck D (2009) Preliminary experience with the hanging maneuver for pancreaticoduodenectomy. Eur J Surg Oncol 35(9):1006–1010

    CAS  Article  Google Scholar 

  36. 36.

    Dokmak S, Aussilhou B, Ftériche FS, Belghiti J, Sauvanet A (2017) Hanging maneuver for stomach traction in laparoscopic distal pancreatic resections: an original technique applied in 218 patients. Dig Surg 34(2):89–94

    Article  Google Scholar 

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Correspondence to Safi Dokmak.

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Dokmak, S., Aussilhou, B., Rebai, W. et al. Up-to-down open and laparoscopic liver hanging maneuver: an overview. Langenbecks Arch Surg (2020). https://doi.org/10.1007/s00423-020-01945-5

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  • Liver hanging maneuver
  • Liver resection
  • Hepatectomy
  • Laparoscopic liver surgery