Flying a kite for liver resection

A simple tip for surgeons and assistants for liver resections.

One of my colleagues reminded me that I had described the traction required on the liver during parenchymal transection as “like flying a kite”. I do worry sometimes that my analogies might seem a little outlandish and this one probably requires a little explanation.

During left or right hepatectomy it is necessary to divide the liver parenchyma along (or close to) Cantlie’s line. Usually we do this in a straight line.

It can be easy to go off course during liver resection and one way of avoiding this is to retract on each side of the liver either side of the line of transection. I do this by holding the lower edge of the liver between finger and thumb usually with a swab for grip and pulling downwards and slightly away from the line of transection. The key thing is that you need to pull with equal force on each side as you develop the line of the transection with your CUSA or whatever device you are using to transect the liver.

If you or your assistant pull too hard on one side you will end up going off course. So pull too hard on the left and the liver will rotate (orange arrow) and the line of transection (yellow arrow) tends to move to the right.

Do the opposite and the line of transection moves over to the left (yellow arrow).

So by varying the traction on each side of the liver you can change the direction of the line of transection of the liver substance. This is a bit like flying a stunt kite which has two control lines where pulling on one side harder than the other is how you get the kite to turn. If you want the kite to hover or stay still you pull both equally.

Going off course during liver resection can result in compromise of tumour margins or straying into hostile territory such as into a hepatic vein. Normally when you are flying a kite you do it on your own. When you do a liver resection you usually have an assistant controlling one side of the liver, perhaps thats why most people can fly a kite but not everyone can resect a liver.

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