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Modified hanging method for liver resection

  • Topics
  • Highly advanced surgery in the hepatobiliary and pancreatic field (Liver Section)
  • Published:
Journal of Hepato-Biliary-Pancreatic Sciences


The liver hanging maneuver (LHM) is a useful technique to transect the liver parenchyma while lifting it with a tape passed between the anterior surface of the inferior vena cava (IVC) and the liver parenchyma. The original method was employed mostly for right hepatectomy with an “anterior approach” for huge liver tumors. The tape serves as a guide to the transection plane and facilitates the control of bleeding in the deeper parenchyma of the liver while protecting the anterior surface of the IVC. On the other hand, several recent studies have shown the feasibility and usefulness of modified LHM techniques. These methods can be applied to left hepatectomy with or without caudate lobectomy (segmentectomy 1), even for patients undergoing orthotopic liver transplantation. This report explains the methods and pitfalls of the original and modified LHM. In addition, important anatomical and technical aspects of the mobilization of hepatic lobes are also included.

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Conflict of interest

The authors declare that they have no conflict of interest.

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Correspondence to Tohru Utsunomiya.

Additional information

This article is based on studies first reported in Highly Advanced Surgery for Hepato-Biliary-Pancreatic Field (in Japanese), Tokyo: Igaku-Shoin, 2010.

Appendix: Important points

Appendix: Important points

  1. 1.

    Confirmation of the roots of hepatic veins: The falciform ligament is divided before mobilizing the hepatic lobes, the subphrenic serosa and connective tissues are dissected approximately 5 cm toward both the right and left sides, and the roots of the three hepatic veins are exposed.

  2. 2.

    Dissection of the coronary and triangular ligaments: Folded gauze is placed behind the lateral segment of the liver before dissecting the left coronary ligament. The left coronary and triangular ligaments are dissected while visualizing the gauze, which can be seen through the ligaments. These precautions prevent injury to the esophagus, stomach, and upper portion of the spleen.

  3. 3.

    Dissection of the anterior surface of the inferior vena cava (IVC): It is important to insert a long light curved Kelly clamp in the proper direction, and advance it toward the space between the right hepatic vein (RHV) and middle hepatic vein (MHV) while the anterior surface of the infra-hepatic portion of the IVC is dissected. The Kelly clamp is inserted through the avascular thin route (middle plane) of the anterior surface of the IVC in the 11 o’clock position (slightly left-sided plane), especially at the cranial site. It is important to strictly avoid forcing the clamp insertion if there is any resistance on the tip (even if it is only very slight).

  4. 4.

    Confirmation of the location of short hepatic veins using ultrasonography:Careful confirmation that there is no short hepatic vein using ultrasonography may help to prevent any unexpected injury to the short hepatic veins during the dissection of the anterior surface of the IVC.

  5. 5.

    Division between the right hepatic lobe and right adrenal gland: The surgeon may use the digital finger (cranial side) and thumb (dorsal side) to confirm that a small amount of connective tissue is left around the right adrenal gland following the mobilization of the right hepatic lobe. A clamp is cranially inserted between the liver and right adrenal gland toward the surgeon’s left index finger placed on the cranial side of the right adrenal gland.

  6. 6.

    Dissection of short hepatic veins: Dissection of the short hepatic veins should be performed very carefully to ensure that there is sufficient length for ligation and division. The stump on the liver side is simply ligated while the stump on the IVC side is secured by Z-sutures using 5-0 monofilament polydioxanone suture.

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Utsunomiya, T., Shimada, M. Modified hanging method for liver resection. J Hepatobiliary Pancreat Sci 19, 19–24 (2012).

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