Flip the Liver for Segment 7 Resection

Abstract

The hepatic segment 7 is considered the most difficult segment to treat due to its anatomical location close to the diaphragm and adjacent to the ribs making it difficult to expose and access during laparoscopic liver surgery (Figure 1). Some authors proposed a transthoracic and transdiaphragmatic approach or intercostal port placement. For a transabdominal approach to Segment 7, we herein describe the “Flip the Liver” maneuver. Four steps are mandatory for success of this trick: i) Thorough mobilization of the right hemiliver including division of the round ligament and dissection of the retroperitoneal reflection ii) followed by pulling the liver caudally towards the patients left leg grasping the falciform ligament or the gallbladder. iii) Ensure anticlockwise rotation and caudalisation of segment 7 and iv) finally check that the Pringle tape exits the abdominal wall through a port at a location permitting to pull the liver in the same caudal direction on the left side. The resulting localisation of segment 7 towards former segment 6 facilitates any liver resection in this segment. “Topographically” segment 7 becomes segment 6, “a posterior segment becomes an anterior segment “(Figure 1). Moreover, the posterior part of segment 7 becomes more accessible for the subxyphoidal port and a resection, preferably using the diamond technique, can be applied safely.