Extended Segmentectomy II to Left Hepatic Vein: Importance of Preserving Umbilical Fissure Vein to Avoid Congestion of Segment III Kosuke Kobayashi,

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Extended Segmentectomy II to Left Hepatic Vein: Importance of Preserving Umbilical Fissure Vein to Avoid Congestion of Segment III Kosuke Kobayashi, MD, Kiyoshi Hasegawa, MD, PhD, FACS, Takashi Kokudo, MD, PhD, Nobuhisa Akamatsu, MD, PhD, Junichi Arita, MD, PhD, Junichi Kaneko, MD, PhD, Yoshihiro Sakamoto, MD, PhD, Norihiro Kokudo, MD, PhD, FACS Journal of the American College of Surgeons Volume 225, Issue 3, Pages e5-e11 (September 2017) DOI: 10.1016/j.jamcollsurg.2017.06.001 Copyright © 2017 American College of Surgeons Terms and Conditions

Figure 1 Pre-, intra-, and postoperative findings of patient 1. (A) Contrast-enhanced CT revealed hepatocellular carcinoma (arrow) located at segment II and invading the left hepatic vein. (B) Estimated resection line and liver volume after 3-dimensional reconstruction. (C) Intraoperative findings after resection. The umbilical fissure vein (arrows) was exposed on the cut surface. (D) Postoperative contrast-enhanced CT showing the patent umbilical fissure vein (arrow) without a heterogeneous enhancement pattern of segment III. (E) Three-dimensional reconstructed image of the liver 3 months after liver resection. The postoperative liver volume of segment III was 108.6% of the preoperative volume of segment III despite the fact that the postoperative total liver volume was smaller than the preoperative total liver volume. Journal of the American College of Surgeons 2017 225, e5-e11DOI: (10.1016/j.jamcollsurg.2017.06.001) Copyright © 2017 American College of Surgeons Terms and Conditions

Figure 2 Pre-, intra-, and postoperative findings of patient 2. (A) Contrast-enhanced CT revealed colorectal liver metastasis (arrow) in segment II, with invasion to the left hepatic vein. (B) Three-dimensional reconstructed preoperative image of the liver and tumors. (C) Estimated resection line and liver volume after 3-dimensional reconstruction. Extended segmentectomy II and limited resection of segment VI were planned. (D) Resected specimen showing invasion to the left hepatic vein (arrow). The surgical margin was negative for cancer. (E) Intraoperative findings after resection. The umbilical fissure vein (arrows) and the stump of the left hepatic vein (arrowhead) were exposed on the cut surface. Journal of the American College of Surgeons 2017 225, e5-e11DOI: (10.1016/j.jamcollsurg.2017.06.001) Copyright © 2017 American College of Surgeons Terms and Conditions

Figure 3 Pre-, intra-, and postoperative findings of patient 3. (A) Contrast-enhanced CT revealed colorectal liver metastasis (arrow) in segment II with invasion to the left hepatic vein. (B) Estimated resection line and liver volume after 3-dimensional reconstruction. Resection of 8 tumors was planned, with extended segmentectomy II and limited resections. (C) Intraoperative findings after resection. The umbilical fissure vein (arrows) was exposed on the cut surface. (D) Postoperative contrast-enhanced CT showing the patent umbilical fissure vein (arrow). A heterogeneous enhancement pattern of segment III was not observed. (E) Three-dimensional reconstructed image of the liver 3 months after liver resection. The postoperative liver volume of segment III was 137.2% of the preoperative volume of segment III despite the fact that the postoperative total liver volume was smaller than the preoperative total liver volume. Journal of the American College of Surgeons 2017 225, e5-e11DOI: (10.1016/j.jamcollsurg.2017.06.001) Copyright © 2017 American College of Surgeons Terms and Conditions