Useful Stapling Techniques in Liver Surgery
Yuman Fong, MD, and Leslie H. Blumgart, MD, FACS
Staplers have become a vital instrument in the
practice of a n u m b e r of surgical specialties. Rectal,
colonic, and esophageal anastomotic instruments
allow safe and rapid anastomosis of the gastroin-
testinal tract even when surgical exposure is com-
promised (1). GIA staplers have greatly facilitated
wedge resection of lung parenchyma (2), and vas-
cular staplers have improved the speed and safety
of lobar resections of the lung (2-4). For liver
resections, however, the use of staplers is not well
established. The literature to date has included
mainly anecdotal reports of vascular ligations or
small segmental resections of the liver (5-9). The
current report presents the experience of a hepa-
tobiliary unit where staplers are routinely used in
liver surgery and describes the technical consider-
ations in using stapling devices in various liver
resections.
H e p a t i c I n f l o w Control
Control of the inflow blood vessels to the liver has
traditionally been achieved by extrahepatic dissec-
tion of the portal vein and hepatic arteries sepa-
rately. Vascular staplers can certainly be used for
stapling the right portal vein or the left portal vein
extrahepatically, and using staplers in s u c h a man-
ner has been described (5, 9). We feel that suture
ligation of the extrahepatic portal veins is such a
straightforward technical exercise that staplers
rarely add to the ease or speed of this ligation, but
they certainly add to the cost. Where we have
found staple ligation to be particularly useful is in
intrahepatic pedicle ligation of the portal pedi-
cles. The pioneering works of Couinaud (10) and
Launois (11, 12) describe the fibrous sheath that
envelopes the entire portal triad and extends into
the liver to the right to form the main right portal
pedicle, which, in turn, splits to form the right
anterior and the right posterior portal pedicles.
On the left side, the left portal pedicle remains
extrahepatic behind segment four where it con-
ReceivedJanuaty 7, 1997; Revised March 3, 1997; Accepted March 7,
1997.
From the Section of Hepatobiliary Surgery, Department of Surgery,
Memorial Sloan-Kettering Cancer Center, New York, NY.
Correspondence address: Yuman Fong, MD, Department of Surgery,
Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New
York, NY 10021.
© 1997 by the American College of Surgeons
Published by Elsevier Science Inc.
tains the left portal vein and hepatic duct. At the
base of the umbilical fissure, the left hepatic artery
also enters the fibrous sheath. There, it gives off
the portal triad to the caudate lobe and then turns
cephalad to reside within the groove in the umbil-
ical fissure. In its intrahepatic portions, therefore,
the fibrous sheath of the portal pedicles contains
the portal vein, hepatic artery, and the bile ducts
to each of the sectors and segments of the liver.
Masligation of the right main portal pedicle has
been well described as a rapid and safe way of
controlling the inflow of blood into the right liver
(11). We have also found that securing the right
anterior pedicle intrahepatically allows facile and
safe control of blood vessels to segments five and
eight (13). Control of the right posterior pedicle
allows division of the inflow vessels going to seg-
ments six and seven (14). In addition, by dissect-
ing at the base of the umbilical fissure, the entire
left portal pedicle can be secured for a rapid
devascularization of the entire left lobe of the
liver, with or without division of the branches go-
ing to the caudate lobe. We will describe here the
technique Of using a vascular stapler in dividing
the various portal pedicles. Use of vascular staplers
in this situation allows simultaneous ligation of the
portal vein, the hepatic artery, and the bile ducts,
and it greatly simplifies hepatic inflow control in
liver resection.
Right main pedicle ligation. Control of the intra-
hepatic portal pedicles is achieved by hepatotomy
in the regions near the portal pedicles (Fig. 1).
Before making an hepatotomy for right hepatic
lobectomy, however, the entire right lobe of the
liver must be mobilized. Most importantly, the
small venous branches draining from the back of
the liver to the vena cava, as well as any large
accessory right hepatic veins, must be divided be-
fore any attempt at securing the intrahepatic por-
tal pedicle. In the securing of portal pedicles the
most dangerous and life threatening complication
is hemorrhage from tearing of these venous
branches draining to the vena cava, or from lacer-
ation of the intraparenchymal hepatic veins. After
complete mobilization of the right lobe of the
liver, the gallbladder is also removed to allow un-
impeded access to the gallbladder bed, as well as
the base of the right portal pedicle. Clamping of
ISSN 1072-7515/97/$17.00
93 Pll $1072-7515(97)00035-5
94 J AM COLL SURe JULY1997 VOLUME185:93--100
FIG 1. Sites for hepatotomy in portal pedicle isolation.
The undersurface of the liver is illustrated. The dotted lines
indicate sites for hepatotomy if control of the intrahepatic
portal pedicles is desired. Incision at 3 allows lowering of the
hilar plate. Incisions at! and 2 allowcontrol of the right main
pedicle. Incisions at 1 and 4 allow control of the right poste-
rior pedicle. Incisions at 2 and 4 allow control of the right
anterior pedicle. Incisions at 3 and 5 allow control of the left
pedicle.
the portal triad in the gastrohepatic ligament
(Pringle maneuver) (15) is usually used to further
minimize blood loss during isolation of the vascu-
lar pedicle. A h e p a t o t o m y is t h e n created across
the caudate process (incision 1 in Figure 1). A
second h e p a t o t o m y is created in the gallbladder
b e d (incision 2 in Figure 1). Ultrasonography
from the inferior aspect of the liver assists in gaug-
ing the d e p t h of the right pedicle, usually 1 to 2
cm from the inferior surface. The right main pedi-
cle is t h e n secured digitally or with a large blunt
clamp and an umbilical tape placed a r o u n d this
structure (Fig. 2). Lowering of the hilar plate (in-
cision 3 in Figure 1) in the back of segment four is
also essential to ensure that the hilum of the liver
is well mobilized and away from the area of staple
ligation. The liver tissue overlying the main right
pedicle is transected, allowing complete visualiza-
tion of the right pedicle. The TA-30 vascular sta-
pler (United States Surgical Corporation, Nor-
walk, CT) is the stapler best suited for this
purpose. Firm traction on the umbilical tape pull-
ing the hilus to the left while applying the stapler
is essential (Fig. 2), because pinching of the tissues
and accidental ligation of the confluence of the
bile ducts is a potential complication of right pedi-
cle ligation. We have been consulted for two pa-
tients where such accidental ligation of the biliary
confluence has occurred, presenting postopera-
tively as obstructive jaundice. It is essential in pa-
tient selection for such right pedicle ligation that
the t u m o r be r e m o t e from the hilum. If the t u m o r
is in proximity of the right portal pedicle, the risk
of violating the t u m o r and c o m p r o m i s i n g the mar-
gin of resection is too high, and extrahepatic con-
trol of the inflow vessels using traditional tech-
niques is r e c o m m e n d e d . In fact, if the t u m o r is
remote from the bifurcation of the anterior and
posterior right pedicles, we favor securing these
pedicles and obtaining inflow control to the right
liver by ligating these pedicles separately. By doing
so, there will be no danger of injuring the conflu-
ence of the bile ducts. A vascular clamp is placed
on the specimen side of the portal pedicle. After
stapling, the pedicle is divided (Fig. 2), a n d the
stapled right pedicle can be oversewn with 4.0
prolene sutures.
Emphasis must again be m a d e on four impor-
tant points. T h e right liver should be mobilized
completely off the vena cava to obviate any poten-
tial for tearing the small hepatic veins from the
cava while securing the portal pedicles. T h e mid-
dle hepatic vein lies in the depths of the anterior
hepatotomy, so vigilance must be maintained to
protect this vein from injury. If t u m o r is located in
proximity to the right portal pedicle, this tech-
nique should n o t be used. Finally, firm counter-
traction on the umbilical tape must b e applied
during application of the stapler to ensure that the
confluence of the bile ducts is n o t accidentally
ligated. The right main pedicle ligation allows
rapid a n d secure division of the inflow of blood to
the right liver. It is particularly useful if previous
surgery involved dissection at the portal hepatis
because identification a n d isolation of the inflow
vasculature in its extrahepatic position can be
challenging in such cases.
Right anterior or right posterior pedicle ligation. The
right anterior or right posterior pedicles can be
secured by first dissecting out the right main por-
tal pedicle and tracing the portal pedicle to its
right anterior or right posterior branch. Alterna-
tively, an incision at sites one a n d four of Figure 1
will allow direct control of the right posterior pedi-
cle (14), and hepatotomies m a d e at incisions two
and four of Figure 1 will allow control of the right
anterior pedicle. There is often a natural crevice
or fold in the right liver along the line m a r k e d by
the n u m b e r four in Figure 1. At the base of this
fold, also known as the recessus dextra of gans, the
posterior portal pedicle can often be visualized
and controlled without a hepatotomy. After con-
trol of these pedicles is achieved, an umbilical tape
should be placed a r o u n d t h e m to use as counter-
 Fong and Blumgart STAPLERSIN LIVER SURGERY 95
traction during application of the stapler. Other-
wise, dividing and oversewing the stumps are as for
a main right pedicle ligation (earlier). The right
posterior pedicle ligation is particularly useful if
contralateral resection in the left liver is necessary.
The right anterior pedicle ligation can be used as
part of a central liver resection, or as part of an
e x t e n d e d left resection (13). No attempt at secur-
ing the anterior or posterior pedicle intrahepati-
cally should be p e r f o r m e d if the t u m o r is nearby,
however, because the benefits afforded by the
technical ease of pedicle ligation do n o t outweigh
,ilieal
FIG 2. (A) Control of the right portal pedicle. After inci-
sions into the liver at sites 1 and 2 in Figure 1, the right portal
pedicle is delivered into view. An umbilical tape is placed
around the pedicle for control. (B) Placement of the stapler.
While constant traction is placed on the umbilical tape to the
right, a vascular stapler is applied on the main right pedicle.
The traction of the umbilical tape prevents accidental appli-
cation of staples too close to the hilus. (C) Division of the
right portal pedicle. After application of the stapler, a vascular
clamp is placed on the specimen side of the portal pedicle.
The right portal pedicle is then cut using a Scalpel.
the longterm detriments of violating the t u m o r
margin.
Leftpedicle ligation. T h e left portal pedicle can be
secured in the region a r o u n d the base of the
umbilical fissure. As with right-sided pedicle liga-
tions, care must be taken to select only patients
whose tumors are n o t near the site of the pro-
posed ligation, so as to minimize the risk of violat-
ing the t u m o r at the margin of resection. Lower-
ing of the hilar plate in site 3 of Figure 1 allows the
isolation of the left portal pedicle with minimal
potential o f injuring the hilus. T h e left portal
 96 J AM COLL SURG JULY1997 VOLUME185:93--100
FIG 3. Stapler ligation of left portal pedicle. After inci-
sions into the liver at sites 3 and 5 in Figure 1, the left portal
pedicle is delivered into view and an umbilical tape is placed
around the pedicle for control. While constant traction is
placed on the umbilical tape downwards, a vascular stapler is
applied on the left main pedicle. The traction of the umbil-
ical tape prevents accidental application of staples too close to
the take off of the caudate branches. After application of the
stapler, a vascular clamp is placed on the specimen side of the
portal pedicle. The left portal pedicle is then cut using a
scalpel.
pedicle may be isolated by h e p a t o t o m i e s in sites 3
a n d 5, as shown in Figure 1. A decision must be
m a d e about the n e e d for resection of the caudate
lobe. If it is to be saved, care must be taken to
ligate the left portal pedicle distal to the origins o f
the b r a n c h e s to the caudate lobe. T h e portal pedi-
cle is isolated and secured using an umbilical tape
(Fig. 3). In securing the left portal pedicle, the
major risk for misadventure is injury to the umbil-
ical vein or the vena cava, which lie immediately
posterior to the left portal pedicle. T h e umbilical
vein is a large venous tributary to the vena cava
that passes b e t w e e n segments III a n d IV and en-
ters the inferior vena cava between and below the
j u n c t i o n of the left and m i d d l e hepatic vein. T h e
distal e n d o f this vein usually lies immediately
b e h i n d the left portal pedicle as it enters the
umbilical fissure. With firm traction downward o n
the umbilical tape, the vascular stapler is applied
across the left portal pedicle (Fig. 3). A vascular
clamp is t h e n placed on the specimen side of the
portal pedicle a n d tile portal pedicle is divided
(Fig. 3). T h e specimen side o f the portal pedicle is
t h e n oversewn with a 3.0 p r o l e n e suture, while the
portal pedicle stump is oversewn with a 4,0 pro-
lene suture. These maneuvers should allow devas-
cularization o f segments II, III, a n d IV, and, w h e n
desired, s e g m e n t I. In this way, isolation a n d divi-
sion of the inflow blood vessels o f the left side can
be accomplished safely a n d rapidly.
Choice of staplers. We have p e r f o r m e d stapled
ligation o f the intrahepatic portal pedicles in m o r e
than 70 patients with no complications directly
attributable to such ligations. We emphasize that
we have b e e n consulted on two cases w h e r e sur-
geons have accidentally ligated the c o n f l u e n c e o f
the left and right bile ducts while p e r f o r m i n g a
m a i n right pedicle ligation. In n e i t h e r case was
counter-traction used while the stapler was being
applied. Lowering the hilar plate in c o m b i n a t i o n
with counter-traction using an umbilical tape are
necessary to avoid such a complication. T h e sta-
pler we have most often u s e d for intrahepatic
portal pedicle ligation has b e e n the TA-30 vascular
stapler, O n occasion, we have also used the E n d o
TA-60 (United States Surgical Corporation, Nor-
walk, CT) vascular stapler w h e n the pedicles have
b e e n very wide.
Outflow Control
Vascular control o f the hepatic veins is an impor-
tant aspect o f major liver resections. Control of the
hepatic veins limits blood loss d u r i n g p a r e n c h y m a l
transection (15). F u r t h e r m o r e , in cases w h e r e tu-
m o r is in proximity of the hepatic v e i n - c a v a l j u n c -
tion, extrahepatic control o f the hepatic veins fa-
cilitates excision o f t u m o r with clearance. Ligating
the hepatic veins can, however, be a technically
d e m a n d i n g exercise. It is dangerous, particularly
w h e n the tumors reside at the d o m e of the liver; a
misadventure d u r i n g this m a n e u v e r is the most
c o m m o n cause o f major intraoperative h e m o r -
rhage (16). E n d o GIA staplers, with their low pro-
file a n d application of staple lines o n b o t h sides o f
the vascular division, can greatly facilitate ligation
o f any o f the major hepatic veins. T h e stapling that
is p e r f o r m e d will n o t only seal the hepatic vein
stump on the vena cava, b u t will also seal the
hepatic vein stump on the s p e c i m e n side w h e r e
sewing is often difficult because of the position
and orientation of the surgical specimen. We will
describe the techniques used for dividing the right
and left hepatic veins in the following paragraphs.
Right hepatic vein ligation. Mobilization a n d iso-
lation of the right hepatic vein should be per-
f o r m e d as previously described (16). Briefly, the
right liver is completely mobilized by dividing the
 Fong a n d Blumgart STAPLERSIN LIVER SURGERY 97
FI6 4. In stapling the right hepatic vein, the liver is ro-
tated to the left and an Endo GIA 30 vascular stapler is
applied at the junction of the right hepatic vein and the vena
cava.
triangular ligament. Care is taken to dissect the
back o f the liver off the right adrenal gland, a n d to
mobilize the liver completely off the anterior por-
tion o f the vena cava. T h e small perforating
b r a n c h e s f r o m the back of the liver to the vena
cava are ligated either with surgical clips or with
ligatures. Attention t h e n focuses o n identifying
any large accessory right hepatic vein that may
originate f r o m the right side o f the cava and e n t e r
t h e liver directly below the m a i n right hepatic
vein. If this accessory right vessel is o f significant
size, it can also be stapled after isolation. Stapling
can be p e r f o r m e d using an E n d o GIA 30 stapler.
In addition, a t o n g u e of liver tissue often passes
f r o m the back o f the right lobe o f the liver poste-
rior to the vena cava a n d connects to the caudate
on the left. We have f o u n d that stapling these
tongues o f liver tissue can be a safe and rapid
m e t h o d for obtaining access to the r e m a i n i n g
v e n a cava. After c o m p l e t e mobilization o f the right
lobe o f the liver, f r o m below and f r o m above, the
right hepatic vein is identified a n d isolated. T h e
liver is t h e n rotated to the left, a n d an E n d o GIA
30 vascular stapler is i n t r o d u c e d f r o m below to,
ward the base o f the h e a r t (Fig. 4). Even t h o u g h
o t h e r authors have described the i n t r o d u c t i o n o f
the stapler f r o m the top of the liver downward (9),
we find that in most patients the liver is sufficiently
high in the surgical w o u n d that this is n o t techni-
cally feasible. T h e stapler is t h e r e f o r e i n t r o d u c e d
parallel to the vena cava a n d directed f r o m below
upwards. Care should be taken to ensure that the
right hepatic vein is within the cutting section o f
the E n d o GIA stapler before closing the stapler.
Care should also be taken to m a k e sure that no
vascular clips are n e a r the site of application of the
stapler to ensure that the stapler does n o t misfire.
In fact, within a b o u t 0.5 cm of the right hepatic
vein, we usually ligate all small p e r f o r a t e d
branches with sutures r a t h e r than with metallic
clips. In our e x p e r i e n c e o f m o r e than 150 liver
resections using stapling o f the right hepatic vein,
there has never b e e n a misfiring o f the stapler, but
the authors have b e e n i n f o r m e d o f one case w h e r e
misfiring of the stapler led to a major h e m o r r h a g e
requiring e m e r g e n c y suture repair. We would n o t
r e c o m m e n d using such a staple-ligation t e c h n i q u e
if visualization o f the right hepatic vein is obscured
by the size or location of tumor, and w h e n suture
repair o f the caval side o f the right hepatic vein
c a n n o t be accomplished if the stapler misfires.
Left hepatic vein ligation. T h e a p p r o a c h to the left
hepatic vein should be p e r f o r m e d as previously
described (16). Mobilization of the left lateral seg-
m e n t off the d i a p h r a g m is accomplished by divi-
sion of the triangular ligament. Dissection is per-
f o r m e d f r o m above the liver a n d f r o m the area
between the back o f the left lateral s e g m e n t (seg-
m e n t II a n d III) a n d the caudate, n a m e l y the
f i g a m e n t u m venosum. In isolation of the left he-
patic vein, caution should be exercised to visualize
b o t h the umbilical vein a n d the middle hepatic
vein because these two structures usually e n t e r the
vena cava in close proximity to the left vein. In
fact, in approximately 60% of cases, the left a n d
middle hepatic vein join t o g e t h e r prior to a com-
m o n entry point into the vena cava. In figating the
left vein, therefore, the m i d d l e hepatic vein must
be protected. After identification of the left vein,
the E n d o GIA 30 vascular stapler is directed f r o m
the top downward (Fig. 5). T h e liver is retracted to
the right for a visualization of the j u n c t i o n o f the
left a n d middle hepatic veins. Division of the left
hepatic vein will allow adequate outflow control
for r e s e c t i o n o f the left lateral s e g m e n t . If a left
h e p a t i c l o b e c t o m y is r e q u i r e d , a d d i t i o n a l dissec-
tion can be m a d e b o t h f r o m above the liver a n d
f r o m below (in t h e r e g i o n o f the l i g a m e n t u m
v e n o s u m ) to identify the m i d d l e h e p a t i c a n d
umbilical veins a n d staple t h e m with a vascular
stapler.
No surgical clips should be placed n e a r the area
to be stapled, as that may cause misfiring o f the
stapler. It is also i m p o r t a n t to m a k e sure that the
entire left hepatic vein comes to lie within the
cutting region o f the stapler.
98 J AM COLL SURG JULY1997 VOLUME185:93-100
Round
ligamen
FIG 5. In stapling the left hepatic vein, the liver is rotated
to the right and an Endo GIA 30 vascular stapler is applied at
the junction of the left hepatic vein and the vena cava.
Choice of staplers. We have found the Endo GIA
30 vascular stapler to be the most useful stapler for
ligating hepatic outflow. The double staple line on
each side of the division is more than adequate for
a low-pressure system such as the hepatic veins.
The authors have performed more than 150 major
hepatic vein ligations using these staple tech-
niques with no complications or misfirings.
Stapler-Assisted Parenchyma Transection
Although there have been reports of left lateral
segmentectomies performed with a stapler (6) and
stapled wedge biopsies of the liver (8), in general
staplers have little utility in the transection of liver
parenchyma. There are few left lateral segments
that would be thin enough for safe application of
staplers, and those that are sufficiently thin for
such application would be easily transected with
normal clamp or finger dissection techniques.
Wedge resections using the stapler would only be
useful around the edge of the liver. In addition,
wedge biopsies around the edge of the liver are
sufficiently basic technical exercises that the use of
staplers is justified only when performing these
biopsies laparoscopically. There are two clinical
scenarios when staplers can be useful in parenchy-
real transection of the liver. These are transection
of cystic disease of the liver, and transection of
parenchyma in treatment of liver abscesses.
Cystic disease of the liver. In the unroofing of
hepatic cysts, staplers can be of assistance. The
advantage of using a stapler is that any inadver-
tently injured bile duct or vasculature is sealed.
This technique is rapid and can be performed
laparoscopically. Figure 6 illustrates the principles
of unroofing a simple cyst. Fenestration of multi-
cystic liver disease is similar. First, the cyst would
be aspirated to ensure that there are no obvious
biliary communications with the cavity (Fig. 6A).
The cyst could then be entered by electrocautery
and unroofed by serial application of an Endo GIA
30 or 60 vascular stapler (Fig. 6B and C). The
parenchymal edges of the cystic lesion can be
transected with confidence in hemostasis. Unroof-
ing of cystic lesions can be done laparoscopically
using staplers, and this has been reported previ-
ously (17).
Liver abscesses. Stapling devices can also be useful
in treatment of complex liver abscesses. In pa-
tients with infected collections within the liver that
are not amenable to percutaneous drainage, the
septic clinical course is often characterized by co-
agulopathy that complicates surgical therapy. Ma-
jor intraoperative goals during unroofing and fen-
estration of complex-cystic infected collection are
maximizing hemostasis and minimizing operative
time. The use of vascular staplers in these situa-
tions allows transection of liver parenchyma with
greater assurance of hemostasis, even in patients
with coagulopathy. Stapling also allows greater as-
surance of sealing any small bile ducts that may be
transected during the fenestration. The liver ab-
scesses are located, and entered by electrocautery.
Then, using Endo GIA 30 or 60 vascular staplers, it is
possible to fenestrate complex abscesses even in the
depth of the liver (Fig. 7).
Conclusions
Progress has been made in improving the safety of
liver resection over the last three decades. Opera-
tive mortality even for extensive resections of liver
p a r e n c h y m a is uniformly less than 5% (18), and
liver resection is the standard and only potentially
curative modality for primary (19) and metastatic
(20) cancers. This progress in liver surgery is ow-
ing in large part to improved understanding of
liver anatomy, and the physiology of recovery from
hepatic surgery. Stapling devices now offer a tech-
nical contribution to the improvement of opera-
tive management. Stapling devices have certainly
been a major advance in surgery, allowing im-
proved speed and safety of many of our gastroin-
testinal anastomoses. They also have allowed lapa-
 F o n g and Blumgart STAPLERS IN LIVER SURGERY 99

~:.. -/ J" . ~ . / "y _ . f% J ~ - -/-.

• "A/AJ4 ~ . - -

"~,k z -
FIG 7. Liver abscess fenestrated with the aid of stapling
A devices. Computed tomography scan demonstrating multiple
complex infected collections in a patient with portal vein
thrombosis, multiple liver abscess, sepsis, and coagulopathy
uncorrectable by blood product transfusion. Abscesses were
fenestrated and infection controlled by unroofing and fenes-
tration of lesions with the aid of Endo GIA 60 vascular sta-
plers. Patient recovered and is well 2 years later.

roscopic surgical therapy for clinical conditions

that could have been treated only by open lapa-
rotomy in the past. This study describes a n u m b e r
of techniques for using stapling devices during
liver surgery that are based on current appreci-
ation of intrahepatic vascular anatomy. We have
f o u n d these staplers extraordinarily useful in
,'x\\
safe ligation of inflow and outflow vessels but are
less enthusiastic about t h e m for transection of
parenchyma.

Acknowledgments

The assistance of Mr. J o h n Forester in illustrating

these procedures is much appreciated.

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FIG 6. Stapler-assisted removal of liver cyst. (A) Cyst is
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