Left Lateral Sectionectomy

Anatomy and indications: 1) Couinaud anatomy - left lateral section comprises segments II (superior, posterior) and III (inferior, anterior); supplied by left portal vein lateral branches and left hepatic artery; venous drainage via left hepatic vein; biliary drainage via left lateral hepatic duct; 2) Anatomic landmarks - falciform ligament marks medial border (umbilical fissure plane); umbilical fissure contains umbilical vein remnant (round ligament), portal venous structures; left hepatic vein lies posterior; 3) Indications - hepatocellular carcinoma in segments II/III in patients with adequate liver function (Child-Pugh A, ICG-R15 <15%); intrahepatic cholangiocarcinoma; colorectal liver metastases; symptomatic benign tumors (hemangioma >5 cm with symptoms, focal nodular hyperplasia >5 cm, adenoma >5 cm or any size in men); hepatolithiasis; living-donor liver transplantation for pediatric recipients (<10 kg); 4) Patient selection - assess hepatic function (Child-Pugh, MELD, future liver remnant volume), comorbidities, performance status; tumor characteristics (size, number, vascular invasion, extrahepatic disease, AFP level); MRI/CT for tumor staging and anatomic delineation; 5) Contraindications - decompensated cirrhosis, severe portal hypertension, advanced extrahepatic disease, distant metastases beyond resectability.

Surgical technique: 1) Approach - laparoscopic now standard (60-80% of LLS in high-volume centers; 4-5 ports; 30-degree scope; CO2 pneumoperitoneum 10-12 mmHg); robotic alternative; open via subcostal or upper midline incision for complex cases; 2) Steps - mobilization of left lateral section by division of round ligament, falciform ligament, left coronary ligament, left triangular ligament; intraoperative ultrasound for tumor localization and assessment of vascular structures; 3) Vascular control - dissection of umbilical fissure, identification and division of segments II and III portal pedicles (portal vein and hepatic artery branches with biliary duct using endo-GIA stapler or clips and division); selective inflow control reduces blood loss; 4) Parenchymal transection - along the umbilical fissure plane (left of falciform ligament), using ultrasonic dissector (CUSA), bipolar energy, harmonic scalpel, or stapler; control of vessels and biliary radicles within parenchyma; left hepatic vein controlled and divided at termination; 5) Specimen extraction - via slightly extended port, Pfannenstiel incision, or umbilical incision in laparoscopic; specimen placed in retrieval bag; 6) Hemostasis and closure - inspection of resection surface, argon beam coagulation, bipolar; closed-suction drain optional in selected cases; 7) Donor procedure variations - more meticulous dissection to preserve graft vascular and biliary anatomy; weight 200-300 g typical for pediatric recipient; intraoperative cholangiography essential.

Outcomes and postoperative care: 1) Operative time - laparoscopic 2-4 hours, open 2-3 hours; experienced surgeons; 2) Blood loss - laparoscopic 100-300 mL median, open 200-500 mL; transfusion rare in experienced hands (<10%); 3) Morbidity - overall 10-20%; bile leak 3-8% (most managed conservatively or endoscopically); pleural effusion 5-10%; intra-abdominal collection 3-5%; wound complications minimal in laparoscopic; 4) Mortality - <1% in experienced centers; 5) Length of stay - laparoscopic 3-5 days, open 5-7 days; 6) Postoperative care - early mobilization (day 1), oral intake (day 1-2), pain management with multimodal analgesia (avoid NSAIDs given hepatic considerations), DVT prophylaxis, monitor liver function tests, drain output if placed; 7) Oncologic outcomes - laparoscopic equivalent to open in oncologic outcomes (R0 resection rates, recurrence-free survival, overall survival); for HCC: 5-year survival 50-70% when performed in selected patients; 8) Living donor outcomes - donor mortality <0.1% in experienced pediatric LDLT programs; donor morbidity 10-20% mostly minor; full liver regeneration within 3 months; 9) Recurrence and surveillance - tumor markers (AFP, CEA, CA 19-9 as appropriate), CT/MRI every 3-6 months for first 2 years, then 6-12 months; treat recurrence as appropriate; 10) Functional outcome - rapid recovery; full activities by 4-6 weeks; pediatric donors typically return to school/activities in 2-4 weeks.