Extended Hepatectomy

Extended hepatectomy — also called trisectionectomy or extended hemihepatectomy — refers to the resection of five or more Couinaud liver segments, removing more than 60% of total liver volume. The two main types are extended right hepatectomy (right trisectionectomy), removing segments 4–8 and sometimes segment 1, and extended left hepatectomy (left trisectionectomy), removing segments 2, 3, 4, 5, and 8. Extended hepatectomy is indicated for large or centrally located tumours — hepatocellular carcinoma, colorectal liver metastases, hilar cholangiocarcinoma (Klatskin tumour), or gallbladder cancer — that require excision of both lobes to achieve negative surgical margins.

Given the large volume of liver removed, preserving adequate future liver remnant (FLR) function is the central challenge. If the anticipated FLR is insufficient (less than 20–30% of total functional liver volume in healthy livers), portal vein embolisation (PVE) is performed 4–6 weeks prior to surgery to redirect portal blood flow to the intended remnant, stimulating hypertrophy. In selected patients, two-stage hepatectomy or ALPPS (Associating Liver Partition and Portal vein ligation for Staged hepatectomy) may be used to achieve complete tumour clearance while generating sufficient remnant volume. These strategies have substantially expanded the resectability of previously unresectable liver tumours.

Extended hepatectomy demands the highest level of hepatobiliary surgical expertise and is performed only at specialised HPB centres with robust intensive care support. Intraoperative considerations include selective vascular inflow occlusion (Pringle manoeuvre), careful management of hepatic venous outflow, and meticulous bile duct reconstruction when required. Post-hepatectomy liver failure is the most feared complication, managed with supportive intensive care and — rarely — emergency liver transplantation. Our surgeons at Ahmedabad Liver Surgeons have extensive experience in extended hepatic resections and employ the full range of liver augmentation strategies to maximise resectability and patient safety.