Laparoscopic hand-assisted right hemihepatectomy by ultrasound-directed intrahepatic approach

Current role of intraoperative ultrasonography in hepatectomy

Hepatectomy had a high mortality rate in the previous decade because of inadequate techniques, intraoperative blood loss, liver function reserve misdiagnoses, and accompanying postoperative complications. However, the development of several modalities, including intraoperative ultrasonography (IOUS), has made hepatectomy safer. IOUS can provide real-time information regarding the tumor position and vascular anatomy of the portal and hepatic veins. Systematic subsegmentectomy, which leads to improved patient outcomes, can be performed by IOUS in open and laparoscopic hepatectomy. Although three-dimensional (3D) computed tomography and gadoxetic acid-enhanced magnetic resonance imaging have been widely used, IOUS and contrast-enhanced IOUS are important modalities for risk analyses and making decisions regarding resectability and operative procedures because of the vital anatomical information provided and high sensitivity for liver tumors, including "disappearing" liver metastases. Intraoperative color Doppler ultrasonography can be used to delineate the vascular anatomy and evaluate the blood flow volume and velocity in hepatectomy patients and recipients of deceased- and living-donor liver transplantation after vessel reconstruction and liver positioning. For liver surgeons, IOUS is an essential technique to perform highly curative hepatectomy safely, although recent advances have also been made in virtual modalities, such as real-time virtual sonography with 3D visualization.