Selection of appropriate liver resection in left hepatolithiasis based on anatomic and clinical study

Because of the possibility of injury to the left medial section of the bile duct (B4) and the presumed higher recurrence rate of hepatolithiasis, some surgeons have recently preferred left hepatectomy for left hepatolithiasis. We investigated the appropriate treatment for left hepatolithiasis by evaluating the anatomy and variations of the left hepatic duct system in a normal population and analyzed the clinical outcome of liver resection.

We reviewed the magnetic resonance imaging results of 115 normal subjects who underwent a workup for living related liver donation. An imaginary surgical resection line was established based on the lateral margin of the umbilical portion of the liver in T2-weighted axial images. The junction of B4 with the left hepatic duct was evaluated to determine the possibility of injury during liver resection. We also analyzed the clinical outcomes of 181 patients who underwent left lateral sectionectomy or left hepatectomy.

The anatomic evaluation showed that B4 joined lateral to the umbilical portion of the liver in 7.0% (8/115) of cases. In patients with left hepatolithiasis, left hepatectomy was performed in 79 patients and left lateral sectionectomy in 102. The operating time for the left lateral sectionectomy was significantly shorter than that for left hepatectomy (p=0.001). There were no significant differences in complications or recurrence of stones.

Preoperative cholangiography should be performed to evaluate the anatomy of the left hepatic duct to avoid injuring B4. For most cases of left hepatolithiasis without a left hilar stricture, left lateral sectionectomy is the safest, most effective treatment.