Left-sided hepatectomy comprises of various anatomical resections: Left hemihepatectomy, extended left hemihepatectomy, left lateral sectionectomy, segmentectomy 2, segmentectomy 3 and segmentectomy 4. There are 5 critical structures for left-sided hepatectomy: main portal fissure, anterior fissure, umbilical fissure, left portal fissure and Arantius duct. We perform left-sided hepatectomy adequately using 5 critical structures.
I will present various anatomical left-sided hepatetomies using transfissural Glissonian approach.
The representative operations are described as followings:
1) Left hemihepatectomy
After cholecystectomy, the hilar Glissonian pedicle is detached from the hilar plate. Nelaton tube is encircled around the left Glissonian pedicle and it is temporarily clamped to find the main portal fissure. The relation between main portal fissure and middle hepatic vein is identified by intraoperative ultrasound. The ventral liver parenchyme is dissected according to the main portal fissure to expose suprahilar Glissonian pedicle. The dissection plane is, then, tilted to left side vertically, and parenchymal dissection is carried out along the ventral margin of the suprahilar pedicle and toward the Arantius duct, making the ventral surface of the paracaval portion of the caudate lobe. In the meantime, middle hepatic vein must be spared if possible, considering its path. The operator uses right second finger to hang the left Glissonian pedicle, identifying the Arantius duct at the left side, and clamps the pedicle at this location with vascular clamp and cuts. The stump is, then sutured continuously, using 5-0 prolene. Ligation of portal pedicle in this location makes possible to overcome anatomical variations within the first-order branches’ level of the portal vein. If we do parenchymal dissection toward the dorsal liver along the Arantius duct retracting the left lobe to the left side, left hepatic vein is exposed. The left hepatic vein is clamped with the vascular clamp, making sure the middle hepatic vein flow is intact, and divided between the clamps. The stump is repaired with prolene 5-0 continuous sutures.

2) Segmentectomy 2
After laparotomy, the left hemiliver is fully mobilized by taking down left triangular ligament. The falciform ligament is held by Kelly clamp, and retracted to the cranial direction. Umbilical fissure is open with CUSA or waterjet dissector at the inferior surface of the liver and Glissonian pedicle of the segment 3 is identified and temporarily clamped. By counter-staining method, the border between segments 2 and 3 can be visualized. The relationship between the left hepatic vein and this plane can be examined by intraoperative ultrasound. The parenchymal transection is performed following this plane, exposing the left hepatic vein. The tributaries of the left hepatic vein are ligated, sparing the left hepatic vein. The parenchymal dissection is continuously carried out until confluence of left hepatic vein to the inferior vena cava. The specimen containing segment 2 can be extracted.

3) Segmentectomy 4
After laparotomy, the tumor location is identified by intraoperative ultrasound, and the relation with the middle hepatic vein is examined. The cholecystectomy is, then, carried out, and the liver parenchyma along the just right side of the umbilical fissure is dissected. The Glissonian pedicles to the segment 4 are ligated in order, using sutures and/or vascular clips. The dissection line of the umbilical fissure is switched to vertical after encountering suprahilar Glissonian pedicle, and parenchymal transection continues along the plane containing Arantius duct and hilar plate detaching the caudate lobe at its ventral surface. According to the right border of the discolored surface of segment 4, main portal fissure is dissected and opened, preserving the middle hepatic vein. The dissection continues to the middle hepatic vein inflow to the IVC, and the segment 4 is extirpated.