Two-Step Hanging Maneuver for an Isolated Resection of the Dorsal Sector of the Liver

Resection of malignant lesions arising in the dorsal sector of the liver is a challenging procedure because the sector is located deep in the abdominal cavity and surrounded by the inferior vena cava (IVC) and the major hepatic veins [1 – 9]. A hanging maneuver is an innovative procedure in hepatic surgeries, in which the liver parenchyma is hung by a tape, thereby making a straight cutting line [10 – 14]. This technique was applied in two patients who had a hepatocellular carcinoma (HCC) in the dorsal sector. Patient 1 was a 46-year-old female, who was found to have an HCC, approximately 3 cm in diameter, located just above the IVC. The patient had a large inferior right hepatic vein (IRHV). The superior right hepatic vein (SRHV) and the IRHV were individually controlled with a tape after dividing several short hepatic veins from the right side of the IVC. A cotton tape was introduced from the groove between the SRHV and the middle hepatic vein (MHV) to the right and left Glisson sheaths via the space just next to the left side of the IRHV. The liver was split into the right and left hemilivers by pulling the tape upwards. Next, the tape was introduced from the space behind the confluence of the MHV and the left hepatic vein (LHV) to the space behind the left Glisson sheath via the fissure of the ligamentum venosum after dividing a few small Glisson branches into the caudate lobe from the left Glisson sheath. The liver parenchyma was divided between the medial sector and the dorsal sector by pulling the tape medially, Finally, the dorsal sector including the tumor was resected by dividing the short hepatic veins from the left side of the IVC. Patient 2 was a 59-year-old male, who was found to have an HCC, approximately 3 cm in diameter, located in the Spiegel lobe (a part of the dorsal sector) during a follow-up for chronic hepatitis B. The tumor compressed the left side of the IVC and protruded inferomedially. Cotton tape was introduced from the groove between the MHV and the LHV to the groove between the right and left Glisson sheaths via the posterior surface of the liver after dividing all the short hepatic