During a right hepatectomy, which structure forms the anatomical boundary between the right and left lobes of the liver on its visceral (inferior) surface?
Answer: B
Explanation: The anatomical division of the liver (based on surface landmarks and peritoneal attachments) differs from the functional division (based on vascular inflow and biliary drainage).
On the visceral (inferior) surface, the gallbladder fossa and inferior vena cava (IVC) mark the boundary between the right and left anatomical lobes.
The falciform ligament marks this boundary only on the anterior (diaphragmatic) surface.
The ligamentum teres (round ligament) lies within the falciform ligament and runs towards the umbilical notch—important in the functional division, not the anatomical one.
The ligamentum venosum separates the left lobe from the caudate lobe posteriorly.
Teaching Points: Teaching Points:
Anatomical lobes are based on peritoneal attachments and surface landmarks.
Functional lobes are based on the distribution of portal triads and hepatic veins (Cantlie’s line).
Cantlie’s line runs from the gallbladder fossa to the IVC — dividing the liver into functional right and left lobes.
Understanding both divisions is essential in hepatic surgery and segmental resection planning.
45-year-old man with chronic hepatitis B is found to have a solitary 3 cm lesion in segment VI of the liver. The lesion enhances in the arterial phase and washes out in the venous phase on CT scan. There is no vascular invasion or extrahepatic spread. What is the best treatment option?
Answer: C
Explanation: For hepatocellular carcinoma (HCC) in a patient with preserved liver function (Child-Pugh A), no portal hypertension, and a single lesion smaller than 5 cm, surgical resection is the preferred treatment. Resection provides excellent long-term survival when hepatic reserve is adequate. Liver transplantation is indicated when there is cirrhosis with portal hypertension or when the tumor meets Milan criteria but resection is not feasible.
Teaching Points: Surgical resection is the treatment of choice for solitary HCC in a non-cirrhotic liver or in cirrhotics with preserved function and no portal hypertension.
A 62-year-old male with Child-Pugh A cirrhosis secondary to HCV (cured with DAAs) presents with a 4.2 cm hepatocellular carcinoma (HCC) in segment 7, abutting the right hepatic vein (RHV) but without macroscopic vascular invasion on triphasic CT. The indocyanine green retention rate at 15 minutes (ICG-R15) is 12%. Future liver remnant (FLR) after a formal right hepatectomy would be 28% of total liver volume (TLV). The patient is not a candidate for two-stage hepatectomy or ALPPS due to portal vein embolization (PVE) failure in the past. Which of the following is the most appropriate next step in management?
Answer: D – Perfor
Explanation: A. Incorrect.
Although PVE is standard to hypertrophy the FLR, the stem states the patient had PVE failure in the past. Repeating PVE is unlikely to succeed and delays definitive therapy. FLR of 28% is borderline in cirrhosis (safe threshold ?30–35% with ICG-R15 <14%), and prior PVE failure precludes this approach.
B. Incorrect.
ALPPS is contraindicated in the question (“not a candidate for two-stage hepatectomy or ALPPS”). Additionally, ALPPS carries high morbidity (up to 40%) and mortality in cirrhotic livers, especially with ICG-R15 >10%.
C. Incorrect.
RFA is suboptimal for a 4.2 cm tumor abutting the RHV. Thermal ablation near major vessels causes heat-sink effect, leading to incomplete ablation and high local recurrence (>30% at 3 years for >3 cm perivascular tumors). Guidelines (EASL, AASLD) recommend resection over ablation for resectable HCC >3 cm in good liver function.
D. Correct.
RHV embolization induces hypertrophy of the left liver (segments 2–4) via venous deprivation, analogous to PVE but targeting outflow. Studies (e.g., Ann Surg 2021) show 15–25% FLR hypertrophy within 3 weeks after RHV embolization, sufficient to push FLR from 28% ? ?35%.
After hypertrophy, segment 7 resection with RHV reconstruction (using a prosthetic graft or autologous vein) preserves right liver outflow for segments 5/6/8, avoiding post-hepatectomy liver failure. This is a venous deprivation + limited resection strategy tailored to perivascular tumors.
Teaching Points: Venous deprivation (RHV embolization) is an emerging adjunct to induce FLR hypertrophy when PVE fails or is contraindicated, especially in tumors abutting major hepatic veins. It enables parenchyma-sparing resection with vascular reconstruction, optimizing both oncologic and functional outcomes in borderline FLR cases. Always integrate ICG clearance, volumetry, and prior embolization response in surgical planning for HCC in cirrhosis.