Theory of Relativity for Posterosuperior Segments of the Liver

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The accessibility to posterosuperior segments of the liver has traditionally constituted a restrain to adopt the laparoscopic approach in this setting. To overcome this challenge, multiple approaches have been reported in literature. Total transabdominal approach has been previously described for this purpose, even though the rationale to standardly adopt it and a technical depiction of how to achieve an optimal mobilization has never been specifically addressed.


Total transabdominal purely laparoscopic approach to posterosuperior segments of the liver is presented, with detailed emphasis to the rotational motions targeted in laparoscopy. A literature review is presented to summarize all other possible accesses to posterosuperior area of the liver. The institutional series for the laparoscopic approach to Sg 7, Sg 6+7, and Sg8 is retrospectively described.


Three rotational motions of the liver are specifically addressed in a video presentation and described for the laparoscopic total-transabdominal approach; the local institutional series using this approach is presented. Other miscellaneous approaches identified from literature encompassing variations in operative position, transabdominal, transthoracic, and combined approaches are described.


Complete mobilization of the ligaments of the liver leads to a rotation of the transection line in front of the operator’s view, allowing to achieve a safe total trans-abdominal laparoscopic approach to the posterosuperior ligaments of the liver, without compromising the vascular inflow control, the possibility to convert to open approach, nor requiring potentially harmful decubitus.

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LA, GF: conception and design; FC, FR, GF, LC: acquisition of data; FR: data analysis and interpretation; GF, FR: manuscript writing; LA, MP, MC: critical review for intellectual content; GF, FR, FC, LC, MC, MP, LA: final approval. All authors are accountable for all aspects of the work and ensure proper investigation and resolution on any question related to the accuracy or the integrity of the manuscript.

Correspondence to G. Fiorentini MD.

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The material has not been previously published or submitted elsewhere for publication and will not be sent to another journal until a decision is made concerning publication. All listed authors have participated in the study and have approved the final manuscript. There is no personal conflicts of interest or financial disclosure for any of the authors. The present study is not based on any previous communication to a society or a meeting.

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Fiorentini, G., Ratti, F., Cipriani, F. et al. Theory of Relativity for Posterosuperior Segments of the Liver. Ann Surg Oncol 26, 1149–1157 (2019).

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