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Complete Caudate Lobectomy"Its Definition, Indications, and Surgical ApproachesAKINORI SASADA*, KEIJI ATAKA KAZUHIKO TSUCHIYA, HIROYUKI YAMAGISHI,HIROMI MAEDA and MASAYOSHI OKADA

Department of Surgery Division II, Kobe University School of Medicine, Kobe, Japan

(Received 12 March 1997; In final form 30 September 1997)

There are three ways to approach and resect thecaudate lobe of the liver, that is; and isolated caudatelobectomy, a combined resection of the liver over-lying the caudate lobe, and a transhepatic anteriorapproach by splitting parenchyma of the liver.We had two patients with neoplasms originating

in the caudate lobe who underwent a completecaudate lobectomy. Both patients have been doingwell without liver dysfunction. Although after thetranshepatic anterior approach we anticipated anadverse effect from splitting the parenchyma of theliver, the postoperative course was uneventful andsimilar to that of the right side approach.

Keywords: Complete caudate lobectomy, neoplasm originat-ing, in caudate lobe, transhepatic anterior approach, rightside approach

combined resection of the caudate lobe has beenemphasized in curative operation for cancer ofthe hilar bile ducts [4, 5]. While the caudatelobectomy for neoplasm originating in thecaudate lobe itself is very rare, and thisprocedure frequently causes a state of confusionbecause of the anatomical difficulty.

In this report we have defined the completecaudate lobectomy as the whole resection of thespigelian lobe, the paracaval portion and thecaudate process [3], and described here how toapproach the caudate lobe and our surgicalexperiences of the complete caudate lobectomy.

INTRODUCTION

Although it has beert demonstrated that varioushepatic resections was carried out safely [1, 2],the caudate lobectomy is still a challengingproblem because of its anatomical complexity [3].The caudate lobe is easily invaded by cancer

of the hilar bile ducts, so that the necessity of

Surgical Anatomy

The caudate lobe consists of the spigelian lobe(the left lobe, or segment I in Couinaud’sclassification), the paracaval portion (the rightlobe, or segment IX in Couinaud’s classification[6]) and the caudate process (Fig. 1). The caudatelobe has some variations of its vascular structure[3, 7]. The arterial branches arise from the left

*Address for reprint requests: Akinori Sasada, MD, Department of Surgery Division II, Kobe University School of Medicine,7-5-2, Kusunoki-cho, Chuo-Ku, Kobe, 650, Japan.

87

APPROACH TO THE CAUDATE LOBE 89

caval portion of the caudate lobe with or withoutimparied liver function.

Patients and Methods

During the last last five years, we have operatedon two patients with neoplasms originating inthe caudate lobe, one large hemangioma andone metastatic liver carcinoma from a rectalcarcinoma.The preoperative liver function was within

normal limits in each patient, and the hepaticparenchyma in each patient was also macro-scopically normal without chromic degenerativechanges.The complete caudate lobectomy for these two

patients is summarized in Table I.Transphepatic anterior approach was chosen in a

36 year-old female patient complaining of con-tinuous back pain with a large hemangioma inthe caudate lobe (Fig. 2a) because the parent wasyoung and their would be minimal loss of theremaining liver.The laparotomy was performed through a J-

shaped abdominothoracic incision with a dia-phragmatic transection.On inspection, the left portion of the spigelian

lobe remained normal. The intraoperative ultra-

(a)

(b)

FIGURE 2

TABLE Complete caudate lobectomy for neoplasm originating in the caudate lobe

Patient No 2

Age/sex 36/Fgross pathology hemangiomaapproach to caudate lobe anteriorcombined resection noneocculsion time of hepatic inflow 90minvascular occlusion Pringle’s maneuverOperation time 11 hrs 40 min

location of tumorin caudate lobe

size of tumorblood lossblood transfusionoutcome

7.0 x 5.0 x 3.0 cm5,600 ml3,000 ml3 y, alive

50/Mmetastatic liver tumor

rightposterior segment

55 minhemihepatic vascular occlusion

7 hrs 30 min

3.0 1.8 2.0 cm1,600 mlnone

y, no recurrence alive

90 A. SASADA et al.

sonography demonstrated that the hemangiomaentirely occupied the paracaval portion andcaudate process. The cranial extremity of he-mangioma was situated at the confluence ofright hepatic vein (RHV) and MHV that drainedinto the IVC. The caudal extremity protrudedbelow the hepatic hilum. The hemangiomadisplaced the IVC posteriosly. After completemobilization of both hepatic lobes, the ligamen-tum venosum between the left hepatic vein andleft portal vein was resected. The liver was thenisolated from both sides of the IVC by dividingand dissecting SHVs. By the hepatic hilarpreparation, glissonian vessels into the portalvein (PV) were divided. The bile duct and thehepatic artery were each encircled with a tape,and then the hilar branches to the caudate lobewere dissected. Under Pringle’s maneuver(clamping for 15minutes and declamping for5 minutes), hepatic transection started along leftwall of the MHV toward the hepatic hilum.Thereafter the hepatic parenchyma was split intwo directions; on the left side toward theresected ligamentum venosum and on the rightside just behind the MHV.

In order to identify the boundary between theright hepatic lobe and the right border of theparacaval portion and caudate process, 15 ml ofindigotindisulfonate sodium solution was in-jected into the right posterior branch of the PV.The right border of the caudate lobe was therebykept unstained and was marked along theunstained margin with an electrocautery. Thecomplete caudate lobectomy was performeden bloc from caudally to cranially. The bleedingfrom the liver raw surface continued untilcomplete removal of the hemangioma occupy-ing the paracaval portion, because its cranialextremity was situated at the confluence of theRHV and MHV into the IVC. The operation timewas 11 hours 40 minutes, and intraoperativeblood transfusion was required for the bloodloss of 5,600 ml. The removed hemangioma was7.0 x 5.0 x 3.0 cm in size and histology revealedcavernous hemangioma.

Right side approach was used in a 50year-oldmale patient who underwent Miles’ operationfor rectal carcinoma three years previously, andwas recently found to have metastatic lesions inthe caudate lobe and segment $6 (Fig. 3a).A thoracoabdominal incision through the

right seventh intercostal space was made. Thediaphragm was diagonally transected towardsthe IVC.

Intraoperative ultrasonography of the wholeliver revealed no other metastatic lesion. There-fore, we decided to carry out the completecaudate lobectomy concomitant with the rightposterior segmentectomy by means of a rightside approach.

After complete mobilization of both hepaticlobes from the abdominal wall and the dia-phragm, the gallbladder was removed to exposethe hepatic hilum. The mobilized lateral segmentwas lifted ventrally to separate the ligamentumvenosum. Since the fissure for the ligamentumvenosum was completely separated, the leftborder of the spigelian lobe was freed from theIVC. The common hepatic duct (CHD) wasseparated and encircled with a tape. By retract-ing the tape around the CHD to the left andupward, the right hepatic artery behind theCHD was encircled with a tape. The surround-ing connective tissue along the right hepaticartery was dissected until its division into theanterior and posterior branches. Subsequentlythe right portal vein (RPV) was separated to beencircled with a tape, and was dissected alongthe RPV up to its bifurcation into the anteriorand posterior branches.Each branch of the RPV was encircled with a

tape, respectively. The vessels to the left lobe ofthe liver were also separated to be encircled witha tape as in the right lobe. The hilar separation ofarterial and portal branches to the caudate lobewas performed. The SHVs were completelyligated and dissected from both sides of the IVC.Next the right posterior branches of the hepatic

artery and portal vein were ligated, the demar-cated area appeared on the surface of the liver.

APPROACH TO THE CAUDATE LOBE 91

We confirmed the RHV by ultrasonography, a follow-up magnetic resonance imaging (MRI)transection line on the liver, at the discolored after 6months of the operation in Patient 2border, was marked on the surface of the liver showed the small cavity around the IVCwith an electrocautery, substituting the resected caudate lobe. TheA hemihepatic vascular occlusion (clamping remnant liver was well hypertrophied. No

for 30minutes and declamping for 10minutes) recurrent lesions were detected on the MRIwas applied to control the blood supply to the (Fig. 3b).right remnant lobe of the liver. The transection Both patients have been doing well withoutalong the intersegmental plane of the right lobe liver dysfunction nor recurrence after 3 yearswas continued toward the freed ligamentum and I year respectively, after complete caudatevenosum. Half way through the transection, lobectomy.each posterior segmental branch of the hepaticartery, portal vein and bile duct was ligateddoubly and dissected at the hepatic hilum. DISCUSSIONAs the posterior segment of the liver was

retracted lateral-ventrally, the complete caudate A neoplasm originating in the caudate lobe islobectomy together with a right posterior seg- very rate [16], so that an isolated completementectomy of the liver was performed as enbloc.The operation time was 7hours 30minutes,

but no blood transfusion was needed. Theresected liver weighed 190gm and containedtwo metastatic tumors. One lesion of3.0 x 1.8 x 2.0 cm mainly occupied the paracavalportion and caudate process, and the other of3.0 x 1.5 x 1.5cm in size located in $6. Thehistological reports of both lesions were adeno-carcinoma derived from the previous rectalcarcinoma.

(a)

POSTOPERATIVE COURSE

The postoperative courses were uneventful inboth patients without any signs of liver failure.The postoperative peak levels of total bilirubinwere 35.7 lamol/1 a.nd 34 tmol/1 on the firstpostoperative day, respectively, and then gra-dually returned to normal values. The antici-pated adverse effect from splitting the liverparenchyma was hardly recognized in Patient 1.

Postoperative computed tomography afterone month in Patient 1 demonstrated the cavityaround the IVC and the free space along the splitline of the liver parenchyma (Fig. 2b). The

(b)

FIGURE 3

92 A. SASADA et al.

resection of the caudate lobe still remains transfusion for 5,600 ml of blood loss. However,unfamiliar to many surgeons, the postoperative liver function was smoothlyOur cases were one hemangioma, and one restored to normal range in a few days without

metastatic tumor from rectal carcinoma and the harmful effects from splitting the liver parench-complete caudate lobectomy was successfully yma in half.performed through the transhepatic anterior In spite of the demerits described above, theapproach and the right side approach combined transhepatic anterior approach, providing anwith a posterior segmentectomy, respectively, excellent surgical view, is safe and gives goodWhen a tumor is too large and mainly located access to perform a complete resection of the

in the paracaval portion of the liver, the caudate lobe [14, 15]. This approach alsotranshepatic anterior approach is generally used preserves the remnant liver function well as into perform the precise surgery [15], although our patient.this surgical procedure is more complex than The right side approach for the caudateother approaches, lobectomy is carried out to simplify the proce-The right border of the paracaval portion, dure [8, 13] or to omit dissection of the unclear

which lies in front and to the right of the IVC, is right caudal border. The hepatic transectionin continuity with the right lobe of the liver, through the intersegmental plane along dorsalFurthermore, between the IVC and the right aspect of the RHV using hemihepatic vascularportal pedicle, the caudate lobe is united with occlusion was simpler anatomically and techni-the right posterior segment of the liver by the cally than a transhepatic anterior approach.caudate process. As it is hard to recognize the Therefore, this procedure had a shorter operat-landmark indicating the boundary of the cau- ing time and less blood loss. However, adate lobe and the right lobe of liver, we used to preparatory or combined resection of the hepaticcounterstainingmethod [17] with injection of the segment or lobe overlying the caudate lobedye into the posterior branch of the PV. The could trigger off postoperative hepatic failureparacaval portion receives a blood supply from even in the normal liver [1, 15]. All the more formany tiny vessels other than the posterior the patient with impaired liver function, asegmental branch [6]. Therefore, a counterstain- combined resection and sacrifice of hepaticing the posterior segment of the liver is parenchyma could easily cause fatal hepaticimpractical but useful clinically [15, 17]. failure.

In comparison with conventional procedures, Recently some authors [10-12] describedthe transphepatic anterior approach has some novel procedures about an isolated caudatedisadvantages of longer operative duration, lobectomy. However, their procedures wouldmore blood loss and harmful effects by splitting be still critical and risky because of the anato-parenchyma of the liver. We thought that the mical complexity and a poor opportunity forresection through the caudal approach would be surgical manipulation in the limited spacemore dangerous in this case, because this behind the main liver lobes. Therefore, an exapproach gives a very narrow surgical field, situ operation has been occasionally recom-and moreover, the hemangioma in Patient 1 mended instead of these difficult proceduresoccupied mainly the paracaval portion and [8, 18].caudate process, its cranial extremity reached We performed the transhepatic anterior ap-the confluence of the RHV and MHV into the proach and the right side approach for theIVC. Indeed, and intraoperative hemorrhage complete caudate lobectomy in two patients.continued until complete removal of the tumor, Both approaches had excellent results withoutrequiring intraoperatively 3,000ml of blood any troubles. Finally, we would emphasize that

APPROACH TO THE CAUDATE LOBE 93

surgeons must give a serious consideration on apatient by patient basis including the occupiedregion of tumor, the remnant liver reserve, andthe vascular structure surrounding tumor inorder to determine the best approach to thecaudate lobe.

Re[erences

[1] Starzl, T. E., Waterman, P. M., Thiel, V. D., Diliz, P. H.S., Dekker, A. and Bron, K. M. (1982). Left hepatictrisegmentectomy. Surg. Gynecol Obstet., 115, 21-27.

[2] Makuuchi, M., Hashikura, Y., Kawasaki, S., Tan, D.,Kosuge, T. and Takayama, T. (1993). Personal experi-ence of right anterior segmentectomy (segment V andVIII) for hepatic malignancies. Surg., 114, 52-58.

[3] Kumon, M. (1985). Anatomy of the caudate lobe withspecial reference of portal vein and bile duct (inJapanese with English abstract). Acta. Hepatol. Jpn., 12,1193-1199.

[4] Mizumoto, R., Kawarada, Y. and Suzuki, H. (1986).Surgical treatment of hilar carcinoma of the bile duct.Surg. Gyncol. Obstet., 162, 153-158.

[5] Nimura, Y., Hayakawa, N., Kamiya, J., Kondo, S. andShionoya, S. (1990). Hepatic segmentectomy withcaudate lobe resection for bile duct carcinoma of thehepatic bilus. World J. Surg., 14, 535-544.

[6] Couinaud, C. (1994). The paracaval segments of theliver. J. Hep. Bil. Pancr. Surg., 2, 145-151.

[7] Nimura, Y., Hayakawa, N., Kamiya, J., Kondo, S.,Nagino, M. and Kanai, M. (1995). Hilar Cholangiocarci-noma-surgical anatomy and curative resection. J. Hep.Bil. Pancr., 2, 239-248.

[8] Elias, D., Lasser, P. H., Desruennes, E., Mankarios, H.and Jiang, Y. (1992). Surgical approach to segment formalignant tumors of the liver. Surg. Gynecol. Obstet.,175, 17- 24.

[9] Lerut, J., Gruwez, J. A. and Blumgart, L. H. (1990).Resection of the caudate lobe of the liver. Surg. Gynecol.Obstet., 171, 160 162.

[10] Colonna, J. O., Shaked, A., Gelabert, H. A. and Busuttil(1993). Resection of the caudate lobe through "bloodygulch", Surg. Gynecol. Obstet., 176, 401-402.

[11] Yanaga, K., Matsumata, T., Hayashi, H., Shimada, M.,Urata, K. and Sugimachi, K. (1994). Isolated hepaticlobectomy, Surg., 115, 757-761.

[12] Takayama, T., Tanaka, T., Higashi, T., Katou, K.,Teshima, Y. and Makuuchi, M. (1994). High dorsalresection of the liveL J. Am. Coll. Surg., 179, 73-75.

[13] Miller, C. M., Schwartz, M. E. and Nishizaki, T. (1991).Combined hepatic and vena caval resection withautogenous caval graft replacement. Arch. Surg., 126,106-108.

[14] Yamamoto, J., Takayama, T., Kosuge, T., Yoshida, J.,Shimada, K., Yamasaki, S. and Hasegawa, H. (1992). Anisolated caudate lobectomy by the transhepatic ap-proach for hepatocellular carcinoma in cirrhotic liver.Surg., 111, 699-702.

[15] Kosuge, T.,Yamamoto, J., Takayama, T., Shimada, K.,Yamasaki, S., Makuuchi, M. and Hasegawa, H. (1994).

An isolated, complete resection of the caudate lobe,including the paracaval portion, for hepatocellularcarcinoma. Arch. Surg., 129, 280-284.

[16] Tung, T. T. (1979). Bilan d’une experience: les resectionsmajeures et mineures du foie. In: Tung, T. T. (Ed) Paris.Masson., p. 127.

[17] Takayama, T., Makuuchi, M., Watanabe, K., Kosuge, T.,Takayasu, K., Yamazaki, S. and Hasegawa, H. (1990). Anew method for mapping hepatic subsegment: Coun-terstaining identification technique. Surg., 109, 226- 229.

[18] Pichlmayr, R., Grosse, H., Hauss, J., Gubernatis, G.,Lamesch, P. and Bretschneider, H. J. (!990). Techniqueand preliminary results of extracorporeal liver surgery(bench procedure) and of surgery on the in situperfused liver. Br. J. Surg., 77, 21-26.

INVITED COMMENTARY

J. BelghitiDr Sasada and his associates are to be con-gratulated for publishing two complete caudatelobectomies using respectively a transhepaticanterior approach and a right side approach.This succcessful result is the result of anexcellent knowledge of the segmental anatomyof the liver an an impressive mastering of liverresection. This paper contains one of the bestillustration of the anatomy of the caudate lobeever published. A good knowledge of thishidden part of the liver which is of extremeimportance in liver surgery because it can beinvolved by tumours. The so-called dorsal sectorby Couinaud consists of segment I, or thecaudate lobe, and segment IX, also named theright paracaval region [1]. This dorsal sector issituated between the IVC and the large (right,middle and left) hepatic veins and the liverhilum. Japanese authors refer to this entire partsimply as the caudate lobe and divide it into aleft part, or Spiegel’s lobe, and a right part [2]. Asurgeon should know that he can see andpalpate only the left part of this dorsal sector,but a large part of this region of the liver ishidden. Dr Sasadas’ description of the access ofthe right part of the dorsal sector through atranshepatic anterior approach in one case andafter complete mobilisation of the right livershould be noticed. According to our experience,

94 A. SASADA et al.

further studies should determine the indicationof primary resection of the left lateral segment(segment I and II) in order to facilitate the accessto the dorsal sector. As experienced by theauthors the situation of the dorsal sectorbetween the IVC and the large hepatic veinsmay cause major bleeding. In this indication weadvocate total vascular occlusion of the liver [3].Although we dramatically restrict our indica-tions of ex-situ procedure, we think that thismethod should be considered in such cases [4].

References[1] Couinaud, C. (1994). The paracaval segments of the liver

J. Hepat Bil Pancer Surg., 2, 145-151.[2] Kosuge, T., Yamamoto, J., Takayama, T., Shimada, K.,

Yamasaki, S., Makuuchi, M. and Hasegawa, H. (1994).An isolated, complete resection of the caudate lobe,including the paracaval portion, for heparocellularcarcinoma. Arch. Surg., 129, 280-284.

[3] Belghiti, J., Noun, R., Zante, E., Ballet, Th, Sauvanet, A.(1996). Portal triad clamping or hepatic vascular exclu-sion for major liver resection: controlled study. Ann.Surg., 224, 155-161.

[4] Sauvanet, A., Dousset, B. and Belghiti (1994). Asimplified technique of "’ex-situ’" liver surgery. TheJournal of the American College of Surgeon, 178, 79-82.

J. BelghitiDepartment of Digestive

Surgery and TransplantationH6pital Beaujon

University Paris VII

COMMENTARY ON MANUSCRIPTCOMPLETE CAUDATE LOBECTOMY:ITS DEFINITION, INDICATIONS,AND SURGICAL APPROACHES

This paper describes two different approachesfor complete caudate lobectomy and the experi-ence gained when using the anterior, transhe-patic and the right-sided approaches. Completecaudate lobectomy is uncommon and can betechnically demanding. The present paper addsto existing experience [1- 7].

The caudate lobe may be excised with aposterior (caudal, dorsal) approach or an ante-rior, transhepatic approach. It appears that aposterior approach is advisable in most patients,and that a transhepatic approach may bereserved for large tumours and especially forcirrhotic livers. Bleeding from hepatic veins isthe main concern during caudate lobectomy,and this may be difficult to avoid or controlunless the liver, including the caudate lobe, canbe fully mobilized. It may be impossible to safelyobtain full mobilization and control with theposterior approach if the tumour is large andfirm and especially if the liver is rigid fromcirrhosis. A transhepatic approach may there-fore be recommended in these situations. Insome patients with liver cirrhosis it is, however,possible to perform a safe posterior resection ifthe hepatic veins can be controlled extrahepati-cally [5-7]. Extrahepatic control of the hepaticveins is advisable also in patients withoutcirrhosis if the tumour is large and/or is closeto the entrance of the (right), middle and lefthepatic veins into the vena cava and may becombined with the transhepatic approach. I haveno experience with the transhepatic approach,but I guess that I would have enucleated thehaemangioma (patient no. 1) using a posteriorapproach and control of hepatic veins.

Surgical strategy should of course be tailoredto the circumstances. Among other things, thisalso means that the posterior approach can berigh-sided or left-sided or alternate between thetwo sides, as emphasized by Bartlett et al. [7].The rule is to operate where it is as "easy" aspossible.The fact that isolated caudate lobectomy is

technically feasible does not mean that it shouldbe used in all patients with malignant tumour inthe caudate lobe. As emphasized by Elias et al.[2], there is risk for inadequate tumor clearancefor anatomical reasons. Thus, in a patient withadequate hepatic reserve one should not hesitateto remove more segments en bloc with thecaudate lobe to ensure free resection margins.

APPROACH TO THE CAUDATE LOBE 95

References[1] Lerut, J., Gruwez, J. A. and Blumgart, L. H. (1990).

Resection of the caudate lobe of the liver. Surgery,Gynecology and Obstetrics, 171, 160-162.

[2] Elias, D., Lasser, P. H., Desruennes, E., Mankarios, H.and Jiang, Y. (1992). Surgical approach to segment formalignant tumors of the liver. Surgery, Gynecology andObstetrics, 175, 17-24.

[3] Yamamoto, J., Takayama, T., Kosuge, T., Yoshida, J.,Shimada, K., Yamasaki, S. and Hasegawa, H. (1992). Anisolated caudate lobectomy by the transhepatic approachfor hepatocellular carcinoma in the cirrhotic liver.Surgery, 111, 699-702.

[4] Colonna II, J. O., Shaked, A., Gelabert, H. A. andBusuttil, R. W. (1993). Resection of the caudate lobethrough "bloody gultch". Surgery, Gynecology and Ob-stetrics, 176, 401-402.

[5] Takayama, T., Tanaka, T., Higaki, T., Katou, K., Teshima,Y. and Makuuchi, M. (1994). High dorsal resection of theliver. Surgery, Gynecology and Obstetrics, 179, 72-75.

[6] Yanaga, K., Matsumata, T., Hayashi, H., Shimada, M.,Urata, K., Sugimachi, K. (1994). Surgery, 115, 757-761.

[7] Bartlett, D., Fong, Y. and Blumgart, L. H. (1996).Complete resection of the caudate lobe of the livertechnique and results. British Journal of Surgery, 83,1076-1081.

Karl-G TranbergDepartment of Surgery

Lund UnversityLund, Sweden

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