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02.01.2018 | original article | Ausgabe 1/2018 Open Access

European Surgery 1/2018

Hilar en bloc resection for hilar cholangiocarcinoma in patients with limited liver capacities—preserving parts of liver segment 4

European Surgery > Ausgabe 1/2018
MD Sven Jonas, MD Felix Krenzien, MD Georgi Atanasov, MD Hans-Michael Hau, MD Matthias Gawlitza, MD Michael Moche, MD Georg Wiltberger, MD Johann Pratschke, MD Moritz Schmelzle
Wichtige Hinweise

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1007/​s10353-017-0507-8) contains supplementary material, which is available to authorized users.
This paper was presented at the 2015 Annual Congress of the German Association of Surgery (DGCH).
The original version of this article was revised due to a retrospective Open Access order.
A correction to this article is available online at https://​doi.​org/​10.​1007/​s10353-018-0559-4.



A right trisectionectomy with portal vein resection represents the conventional approach for hilar cholangiocarcinoma. Here, we present a technical modification of hilar en bloc resection in order to increase the remnant volume by partially preserving liver segment 4.


The caudal parenchymal dissection line starts centrally between the left lateral and left medial segments. Cranially, the resection line switches to the right towards Cantlie’s line and turns again upwards perpendicularly. Hence, segment 4a and subtotal segment 4b are partially preserved by this novel technique. The left hepatic duct is dissected at the segmental ramification and reconstruction is performed as a single hepaticojejunostomy. The feasibility of the novel parenchyma-sparing approach for hilar cholangiocarcinoma was proven in a case series and medical records were reviewed retrospectively.


Ten patients (6 male, 4 female) underwent segment 4 partially preserving right trisectionectomy for hilar cholangiocarcinoma. Estimated future liver remnant volume was significantly increased (FLRV 38.3%), when compared to standard right trisectionectomy (FLRV 23.9%; p < 0.01). Three of 10 liver resections were associated with major surgical complications (≥IIIb; n = 3); categorized according to the Dindo–Clavien classification. No patient died due to complications associated with postoperatively impaired liver function. Tumor-free margins could be achieved in 8 patients while median overall survival and disease-free survival were 547 and 367 days, respectively.


This novel parenchyma-sparing modification of hilar en bloc resection by partially preserving segment 4 allows to safely increase the remnant liver volume without neglecting principles of local radicality.

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