In parallel with efforts to replace the entire organ, surgeons would become emboldened to split this divine structure—almost deified as lodging for the soul itself by contemplative ancients—in any number of innovative manners. Starzl’s passion for transplantation only engendered a mounting curiosity and mastery of the partial hepatectomy. During those early years of liver allografting, he and his team performed 27 liver resections including 14 “trisegmentectomies,” or what had formerly been called topographic right lobectomies—without a single postoperative death. Starzl referred to this operation as removal of the “true right lobe” plus the medial segment of the “true” left lobe—terms synonymous with right and left livers of Couinaud, split by the interlobar plane of Cantlie. For the trisegmentectomy he used an abdominal approach, discouraging the thoracic extension that, he felt, contributed significantly to postoperative morbidity. Hilar control was followed by control of the right hepatic vein. “This maneuver is potentially dangerous,” he wrote, “because the hepatic vein is extremely short and because a tear during the dissection would create a defect in the side of the vena cava that would be difficult to control or repair,” an opinion certainly shared by anyone who has tried to force a clamp around this structure, barely visible as it emerges from liver substance to join the vena cava. Improperly done, the operating surgeon will be greeting by a seemingly unstaunchable flow of venous blood. Another technical note was his insistence on leaving a margin of viable medial segment (segment IV) that is meant to preserve nutrient vessels and biliary drainage to and from the lateral sector. Splitting of the liver itself was done by crushing maneuvers with ligation of intraparenchymal branches, the same technique taught by virtually all liver surgeons before the age of hemostatic energy devices. The last structure encountered was the fat middle hepatic vein, draining the central liver, Couinaud Segments IV, V, and VIII. It was to be taken at its origin from the left hepatic vein or directly from the vena cava (all descriptions from ).
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