title: The posterior intrahepatic approach to the left portal pedicle using the ligamentum venosum: anatomical basis.
abstract: OBJECTIVE
  Prevention of blood loss in liver resections is essential for reducing postoperative morbidity. The main method to control bleeding during surgery of the left hemiliver is occlusion of the left portal pedicle. This may be accomplished by hilar, fissural or posterior intrahepatic techniques. However, these techniques may injure transposed vessels or bile ducts from the right portal pedicle to the left. The purpose of this study was to describe the anatomical aspects of the posterior intrahepatic ligamentum venosum approach to the left portal pedicle.
  
  
  METHODS
  Anatomical study was carried out on 215 isolated adult livers. In 57 specimens, sections of the extra- and intrahepatic portions of the left portal pedicle were prepared under stereoscopic microscopy.
  
  
  RESULTS
  The ligamentum venosum is the anatomical landmark between the medial and lateral portions of the left portal vein. The convergence of the ligamentum venosum along the left portal pedicle is where the left portal sheath reaches its maximal thickness and these connections are tight. In 8-12%, the medial portion of the left portal pedicle includes a transposed right paramedian vein or right-sided bile ducts.
  
  
  CONCLUSIONS
  According to our anatomical study, we believe that it is possible to use the ligamentum venosum as an anatomical guide to achieve a controlled approach of the left portal pedicle during left-sided hepatectomies. Moreover, ligation of the left portal pedicle at its convergence with the ligamentum venosum may prevent erroneous injury of transposed right paramedian vessels or bile ducts.
authors: Department of Surgery C and Surgical Oncology, Chaim Sheba Medical Center, 52621, Tel Hashomer, Israel. sareli.marom@sheba.health.gov.il
authors: Merab
authors: M
authors: Sareli
authors: Ilia
authors: I
authors: Chanukvadze
authors: Adrian
authors: A
authors: Valeanu
authors: Douglas B
authors: DB
authors: Zippel
authors: Ron
authors: R
authors: Shapiro
authors: Moshe Z
authors: MZ
authors: Papa
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical / Q000517:prevention & control; D002102:Cadaver; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D008022:Ligaments / Q000033:anatomy & histology*; D008099:Liver / Q000098:blood supply*; D008297:Male; D008875:Middle Aged