Figure 5.

(A) The right hepatic vein is adequately skeletonized and then hanged with a Penrose drain. (B) Delicate and detail-oriented retraction/countertraction is performed with the finger, and general and rough retraction/countertraction is performed with the hand (blue arrows). Use of a laparoscope with pneumoperitoneum provides an excellent surgical field under the left phrenic space. (C) The left hepatic triangular ligament is cut. (D) The cut ends of the membranes from the central and left sides are connected. Injury to the phrenic veins should be avoided. The dissectible/cuttable layer is very wide, as is the right side, and should be intentionally traced as close to the liver as possible (red arrow). (E) Direct vision with an extensional incision provides a preferable surgical field for procedures involving hanging of the left hepatic vein and middle hepatic vein. Direct vision requires focal lighting (aqua area). The pinch-burn-cut technique is useful for dissections around the inferior vena cava. (F) The division between the middle and right hepatic veins is detected (green line) and dissected through the anterior wall of the inferior vena cava (green arrow). Adequate retraction of the liver is performed (blue arrow). (G) The inferior vena cava wall should be completely bared at the upper side of Spiegel’s lobe. The pinch-burn-cut technique works well for this purpose. (H) The phrenic vein is ligated (black arrows) if needed. A perfect dissection of the connective tissues should be completed, especially on the upper side of Spiegel’s lobe (yellow area) HCL, hepatocaval ligament; HSE, hook-shaped electrode; IVC, inferior vena cava; LHTL, left hepatic triangular ligament; RAG, right adrenal gland; RHV, right hepatic vein