Revisiting the Intersegmental Plane in Anatomical Liver Resection: A Three-Zone Framework Beyond Hepatic Vein...

Area of Science:

• Hepatobiliary surgery
• Surgical anatomy
• Medical imaging

Background:

• Accurate identification of intersegmental planes is crucial for anatomical liver resection (ALR).
• Traditionally, hepatic veins are used as landmarks, but portal territory boundaries can deviate.
• Advances in 3D reconstruction and indocyanine green (ICG) imaging highlight discrepancies.

Purpose of the Study:

• To propose a novel three-zone classification for intersegmental planes in ALR.
• To guide surgical strategy by defining planes based on their relationship with hepatic veins.
• To improve preoperative planning and intraoperative decision-making for safer ALR.

Main Methods:

• Development of a three-zone classification (Exposure, Crossing, No Exposure) for intersegmental planes.
• Analysis of spatial relationships between intersegmental planes and hepatic veins.
• Integration of 3D reconstruction and ICG fluorescence imaging concepts.

Main Results:

• Zone 1 planes run alongside hepatic veins, offering clear landmarks but risking injury.
• Zone 2 planes intersect hepatic veins, posing a high bleeding risk.
• Zone 3 planes are parenchymal, minimizing bleeding but requiring ICG guidance.

Conclusions:

• Intersegmental planes are best defined as Glissonean-free watersheds, not just by hepatic vein location.
• The proposed zone-based classification aids in anticipating venous exposure during ALR.
• This framework optimizes dissection techniques for more precise and safer anatomical liver resections.