Hepatectomy with initial suprahilar control of intrahepatic portal pedicles.

In 1985 Couinaud described an original technique for left hepatectomy. This technique is based on initial control of the left intrahepatic portal pedicle after wedge incision of the hepatic capsule is made and the hilar plate is lowered before the hepatic parenchyma is opened. The vascular and biliary pedicular elements are dissected concomitantly at a point where they are protected by and contained within a sheath emanating from the hepatic capsule. After elective clamping of the pedicle at this level is done, the territory to be removed becomes obvious by the change of color produced by ischemia, and bleeding is minimized preventively. Although Couinaud's technique concerned only one case of left hepatectomy, we confirmed the ease, safety, and reproducibility afforded by this technique in four left hepatectomies. Based on the same principles, this technique may be used for other types of hepatic resections, notably, left hepatectomy extended to segments 5 and 8 (trisegmentectomies). We report our experience with this technique in 15 cases of major hepatic resections.