EXTENDED LEFT LOBECTOMY WITH PRESERVATION OF THE INFERIOR RIGHT HEPATIC VEIN FOR A CHOLANGIOCARCINOMA INVOLVING THE HEPATOCAVAL CONFLUENCE.

After an extended hemihepatectomy adequate venous drainage of the remaining liver is required in order to preserve hepatic function. Most liver tumours involving the confluence of the hepatic veins are considered unresectable because hepatic venous outflow after resection would be compromised. In 10-25% of people, the inferior right hepatic vein presents large calibre. Thus the superior hepatic veins may be sacrified and hepatic function preserved if a large inferior right hepatic vein is present. The video describes a case of cholangiocarcinoma involving the dome of the liver, all the three hepatic veins and the portal pedicle to the VIII segment. The patient was a 78 old years woman in good general conditions and liver function. At the CT scan she had a large inferior right hepatic vein draining the posterior liver sector. The patient was treated by an extended left hepatic lobectomy with resection of the main right, left and middle hepatic vein and preservation of the inferior right hepatic vein. The video also shows the technical solution (an omental flap like an hammock fixed to the diaphragm) adopted to preserve a good venous drainage of the residual posterior sector hampered by the kinking of the inferior hepatic vein. The patient is still alive after 18 months of follow-up but a recent CT scan showed three distant liver metastasis actually treated with chemotherapy. This case confirms that a hepatic lesion involving the dome of the liver, apparently unresectable can turn resectable if an alternative venous drainage is present. In these cases a pre-operative search for an inferior right hepatic vein is mandatory and is easily accomplished by ultrasound and computerized tomography.