A technique for safely teaching major hepatectomy to surgical residents

In this era of combination chemotherapy and biologic treatment, the ability to downsize tumors that were previously unresectable will increase the need for major hepatic resections. This makes teaching consistent surgical approaches to these difficult cases imperative. Herein we outline a standardized surgical approach to right hepatectomy, which allows the procedure to be divided into a series of well-defined technical maneuvers. Preoperative preparation and communication with anesthesia to ensure a low central venous pressure is emphasized. A right hepatectomy is described by dividing the procedure into 5 steps: (1) initial mobilization and intraoperative ultrasound, (2) cholecystectomy and extrahepatic inflow occlusion and, (3) posterior mobilization and extrahepatic venous outflow ligation, (4) parenchymal transection, and (5) hemostasis and closure. Such techniques, once adopted by the surgeon, will allow for controlled parenchymal transection, minimal need for inflow occlusion to the liver remnant, and safe and efficient hepatectomy.