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Extended Right Hepatectomy in a Liver with a Non-bifurcating Portal Vein:

The Hanging Maneuver Protects the Portal System in the Presence of
Anomalies

Article  in  Journal of Gastrointestinal Surgery · February 2013

DOI: 10.1007/s11605-013-2161-1 · Source: PubMed

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J Gastrointest Surg
DOI 10.1007/s11605-013-2161-1

CASE REPORT

Extended Right Hepatectomy in a Liver with a Non-bifurcating

Portal Vein: the Hanging Maneuver Protects the Portal System
in the Presence of Anomalies
Ser Yee Lee & Daniel Cherqui & Michael D. Kluger

Received: 14 January 2013 / Accepted: 29 January 2013

# 2013 The Society for Surgery of the Alimentary Tract

Abstract
Introduction Variations in portal vein anatomy occur in 20–35 % of individuals. A non-bifurcating portal vein (PV) was
suspected on preoperative imaging in a patient with a large right lobe hepatocellular carcinoma. The single PV curved within
the liver parenchyma from right to left supplying second-order branches along its course.
Case Report Utilizing the hanging maneuver, an extended right hemihepatectomy was safely performed. This approach
allowed for preservation of the main PV and its left-sided branches while easily identifying the second-order right branches
for ligation.
Conclusion Knowledge of portal vein variations and identification preoperatively by cross-sectional imaging are
critical. The hanging maneuver aids in the preservation of the main portal vein and its left-sided branches during
right hemihepatectomy in the presence of portal vein anomalies, and this technique can be used to improve safety in
hepatobiliary surgery.

Keywords Surgical technique . Hepatectomy . Hanging
maneuver . Portal vein anatomy
Introduction
Classically, the portal vein divides into right and left
second-order branches, and then further divides within
the parenchyma into third-order branches. This branching
pattern is observed in about 65 to 80 % of cases.1–3 There
are several portal vein anomalies that make up the
remaining 20–35 % of cases.2–4 Cheng and colleagues
S. Y. Lee : D. Cherqui : M. D. Kluger (*)
Section of Hepatobiliary Surgery and Liver Transplantation,
Department of Surgery, New York-Presbyterian Hospital/Weill
Cornell Medical Center, 525 East 68th Street,
New York, NY 10065, USA
e-mail: mik9020@med.cornell.edu
classified portal vein anatomical variations as types I to
IV and Nakamura and associates described a similar
classification, albeit with five variations (A to E); these
two classifications are summarized in Fig. 1.5,6 Absence
of the portal vein bifurcation (APVB) is a rare anomaly.
Initially described by Couinaud in 1957, it has been
reported in 0.03–2 % of cases in various cadaveric
and radiographic studies.7–11
Knowledge of portal vein variations is crucial for
liver surgeons to perform major liver resections and
living donor operations safely.10 Such knowledge allows
for the selection of the optimal surgical approach and
techniques to minimize intraoperative and postoperative
complications. Failure to recognize portal vein anoma-
lies prior to extrahepatic vascular control can lead to
disastrous outcomes due to ligation of the portal
branches reaching the contralateral left liver remnant.11,12
Alternatively, excessive portal bleeding can occur after
extrahepatic control if unrecognized major branches derive
from the contralateral portal vein.

Fig. 1 Classification of portal vein anatomy.5,6 PV, portal vein; RAS, right anterior sectorial branch; RPS, right posterior sectorial branch; S,
segmental branches
The liver hanging maneuver described in 2001 by Bel-
ghiti is commonly applied to right hepatectomies as an
adjunct to the anterior approach.13,14 This facilitates right
hemihepatectomy without liver mobilization and has the
advantages of shortened operative time, reduced malignant
dissemination, improved remnant liver mobilization and
function, better surgical exposure, transection, hemostasis,
and cava protection.15 This technique has been modified for
other resections such as left hemihepatectomy with or with-
out caudate resection, extended right hepatectomy with
J Gastrointest Surg
caudate lobectomy, and even living donor hepatectomy
and laparoscopic approaches.15–17
Here, we describe how the hanging maneuver can be
used to protect and preserve the anomalous portal vein
and its branches during right or extended right hepatec-
tomies; such protection is unnecessary for left or ex-
tended left hepatectomies. Specifically, we present the
use of the hanging maneuver in a patient without a
portal vein bifurcation undergoing an extended right
hepatectomy for a large right hepatocellular carcinoma.
J Gastrointest Surg

Case Report

An 83-year-old gentleman with no history of liver dis-

ease was referred to our institution for evaluation of an
incidental liver mass found on abdominal sonography
ordered in response to abnormal liver function tests.
MRI of the liver revealed a 13×9×11 cm mass in seg-
ments 5 and 8 with a tumor thrombus extending into the
middle hepatic vein and a subcentimeter nodule in seg-
ment 4. The lesion had radiological features consistent
with a hepatocellular carcinoma (Fig. 2). After meta-
static, cardiac, and hepatic evaluations, and discussion
at multidisciplinary tumor board, the patient was offered
an extended right hemihepatectomy. The future liver
remnant was estimated to be 35 %.
The patient was placed in supine position and a J-
shaped incision was used to enter the peritoneal cavity.
After excluding peritoneal metastases, intraoperative ul-
trasound confirmed the extent and location of the tumor
and tumor thrombus in the middle hepatic vein. After
cholecystectomy, the hilum was dissected from right to
left, the right hepatic artery was ligated and transected,
and the portal vein was dissected at the hilum and
encircled with a vessel loop. The right posterior portal
vein was partially extrahepatic, similar to the position-
ing of the classic right portal vein. It was ligated and
transected.
Fig. 2 Preoperative imaging with three-dimensional reconstruction: a
After intraparenchymal dissection of the plane be- cross-sectional view of the hepatocellular carcinoma (thick arrow) and
tween the middle and left hepatic veins, an umbilical the single non-bifurcating portal vein (long thin arrow); splenic vein
tape was passed from inferiorly along the anterior sur- (short thin arrow); b Three-dimensional vascular reconstruction of the
face of the vena cava to the convergence of the middle PV (long arrow) and splenic vein (short arrow)
and left hepatic veins superiorly. A transection plane
was outlined just right of the falciform ligament for
the planned extended right hemihepatectomy. Parenchy-
mal transection was performed using an ultrasonic dis- transection of the right hepatic vein with a linear vascular
sector/aspirator (Cavitron Ultrasonic Surgical Aspirator, stapler. Figure 4 shows the liver remnant and the preserved
CUSA System, Valleylab Inc., Boulder, CO), bipolar portal vein in situ at completion of the operation.
diathermy, and clips under intermittent Pringle maneu-
ver. As transection continued, the hilar plate was
opened, and division and closure of the right anterior Discussion
and posterior bile ducts was performed. Using the hang-
ing maneuver, the umbilical tape was naturally guided Absence of bifurcation of the portal vein is a rare
along the right lateral surface of the intraparenchymal variant that poses a significant technical challenge dur-
portal vein allowing for the easy identification of the ing liver resection.3 It is potentially disastrous if not
individual second-order veins supplying segments V– recognized and highlights the importance of good pre-
VIII and IV (Fig. 3) without risking the main trunk of operative contrast enhanced imaging for precise surgical
the intraparenchymal vein. After controlled transection planning.11,12 Failure to recognize this anomaly resulted
of each of these second-order branches, the parenchymal in ligation of the common portal vein leading to com-
transection plane was aligned with the falciform and complet- plete portal vein (PV) thrombosis, devascularization of
ed inclusive of the middle hepatic vein with the tumor throm- the left liver, and resultant multi-organ failure and death
bus. The extended right hemihepatectomy was completed by in one report; it was misconstrued as the right portal
 J Gastrointest Surg

Fig. 3 Anatomy of the single

non-bifurcating portal vein and
the modified liver hanging
maneuver: a illustration of the
anatomy of the single non-
bifurcating portal vein; b use of
the tape in a modified liver
hanging maneuver to protect
the intrahepatic PV and in
identification of the individual
right segmental branches

vein.11 Recently, Spampinato and colleagues also reported
a case of APVB and their surgical technique to perform a
safe right hepatectomy. With a preoperative three-
dimensional vascular reconstruction CT scan for planning,
intraoperative ultrasound, cavitation aspiration system,
and individual vessel loops, they identified the trans-
verse portion of the aberrant left branch of the PV
intraparenchymally and followed the dissection on the
external side of the arch toward the right to preserve the
portal vascularization for the left remnant liver.10
We describe a modified hanging maneuver in a challenging
case with a large right HCC requiring an extended right
hemihepatectomy. The hanging facilitated the parenchymal
transection with minimal manipulation in this patient with
distal middle hepatic vein tumor thrombus. Perhaps more
importantly, it allowed for intraparenchymal identification of
the variant anatomy of the APVB. The tape guided the deep
transection plane along the course of the non-bifurcated portal
vein as it initially veered to the right, giving off its right-sided
posterior and anterior branches before changing its course
toward the left liver. The tape precisely identified the portal
branches and allowed controlled ligation of these branches as
it hooked around them. The hanging tape improves the iden-
tification of individual segmentary branches as it hooks
J Gastrointest Surg

opposed to the classic hanging maneuver where the tape lies

against the parenchyma at the bifurcation of the left and right
portal vein after ligation of either, utilization of the hanging
maneuver in the presence of a portal vein variation allows for
the tape to “catch” against each second (current case) or third-
order branch, like cogs on a wheel. The branch can then be
ligated and transected as necessary while insuring preserva-
tion of the portal vein and perfusion of the remnant segments.
In this manner, complete preservation of portal flow to the left
remnant liver is safely achieved.
Review of the literature showed three to five patterns
of portal vein branching, mainly with regard to the
existence of a main trunk and variation of the right-
sided branches.4,5 As described earlier, Cheng et al. and
Nakamura et al. described a classification of four and
five types, respectively. The variant in our patient was
previously reported, but not illustrated in the current
classifications.3,5 This variant is significant as it can
lead to total remnant portal devascularization if not
suspected preoperatively in liver resections or living
donor hepatectomies (Fig. 1).

Conclusion

Portal vein variations are common and it is important

for surgeons performing major liver resections or split
transplantations to be aware of variations preoperatively.
We highlight the existence of a rare but important
variant outside of the current classification to heighten
safety in both hepatobiliary surgery and liver transplan-
tation. We report our surgical technique of using a
modified hanging maneuver to preserve adequate portal
vein in-flow in the case of a single non-bifurcating
portal vein that can be safely generalized to right or
extended right hepatectomy in the presence of any of
the portal venous anomalies.

Acknowledgments We would like to acknowledge Dr. Krishna

Juluru and Ms. Adrienne B. Coya from the Imaging Data Evaluation
& Analysis Laboratory, Weill Cornell Department of Radiology for
their assistance in image requisition and optimization.
Fig. 4 Intraoperative and postoperative images: a post-resection, intra-
operative photo of left lateral liver remnant (segment 2/3) and the Conflict of Interest No disclosures and no grant support.
preserved portal vein (short arrow) with right segmental branches tied
off (long arrows). b Postoperative cross-sectional CT imaging showing
the left lateral liver remnant and the preserved portal vein (arrow). c
Postoperative coronal section on CT; portal vein (arrow) References

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