The development of liver surgery

From the late 19th century through experimental animal studies, has been established through the liver parenchyma incision is feasible, liver resection of the 3 / 4, animals can still surviving, and more than can be regenerated liver in order to achieve its original size. Carl Langenbuch (1888) is considered the first successful implementation of the left hepatic lobe resection, but Langenbuch "patient" is a 30-year-old woman, abdominal pain because their belly, he found in liver on the left lobe of a mass, its pedicle ligation after resection of the weight of 370 g, that is due after Waist hard the oppressed by the liver, but after surgery the hepatic portal vascular hemorrhage, Langenbuch also done a second time for the surgery, the patients cured after all. Therefore, Langenbuch is considered a destination for the purposes of liver resection of the first surgeons. Lucke (1891) from the initial report of a left hepatic lobe resection of tumor and Wendel (1911) with right lobe of the liver. William William Keen (1899) be identified For the first liver resection of the American surgeon, when he reported three cases of successful surgery.
  the development of modern science and technology has allowed for extensive liver resection. Today's liver surgeon must have superb skills teeth, a well-known human physiological and metabolic processes, and has a vast knowledge of modern science and technology, so surgery can achieve good results. The appearance of the human body is unaware of the liver as a whole, in the past has been the falciform ligament as liver left and right boundaries until 1888 Rex passed few mammalian liver rot Corrosion specimens observed that the portal vein left and right branches constitute two of the liver. 1898 Cantlie found around the liver is equal semi leaf from the gallbladder fossa through the inferior vena cava to the plane separated from Waterloo, later said that the line for the Rex-Cantlie line. With the anatomy of the initial understanding of the liver, surgeons began operations. 1909 VonHaberer left hepatic artery ligation of the left hepatic resection; 1911 Wendel in the right hepatic artery ligation outside the liver and right hepatic duct along the right lobe of the liver resection Cantlie line was started anatomy and the combination of surgery and promote the development of liver surgery. Subsequently, Wangensteen (1945) in the block under hepatic resection right lobe of the liver blood flow; Lortat-Jacob (1952), Quattlebaum, Pack and so have control of hepatic blood flow in the right lobe of the liver resection.
2 liver bleeding and bleeding
  throughout the entire liver surgery question is "bleeding" and "stop bleeding." The liver is one college as full of blood "sponge", no matter how she is to you, always bloodshed, and more than a stream. For many years, surgeons were racking's minds this has been, I do not know how many have tried methods to stop bleeding, and some even appear in the current method is laughable.
  until 1908, Pringle in the United States, "surgical Yearbook" magazine (Annals of Surgery) published an article entitled "Notes on hemostasis liver injury" (Notes on the arrest of hepatic hemorrhage due to trauma.) , Reported eight cases of liver trauma patients, four cases of dead before surgery, one case of refusing surgery, three cases for the purposes of a Caesarean section, surgery Pringle with his thumb and fingers pinching hepatic pedicle to temporarily stop bleeding that night able to see clearly, although the three cases patients were subsequently died, but Pringle spent three rabbit experiments to prove his envisaged is correct. Pringle papers published, it has responded quickly, this will become a way to stop bleeding liver surgical breakthroughs, still commonly used, and was later called Pringle practices (Pringle's maneuver). 1953 Rafucci through the experimental dogs, dogs can be made safe tolerance hepatic portal blood flow occlusion 15 min. This is still the standard has been adopted by the clinical basis, but we proved clinical hepatic portal blocked at room temperature up to 60 min time limit, or even how long is the limit, are still not identified. In the 1950s, Child spent many years of time to study blocked portal vein and hepatic artery of the issue, he discovered that the portal vein occlusion tolerance of different species of experimental animals are very different, such as rabbits, dogs, cats do not tolerated long blocked portal vein, but monkeys managed to survive long. Child and reported two cases of portal vein ligation after the patient did not have any adverse results. Child in 1954 published research on liver blood circulation of monographs that his 19 monkeys (Macaca mulatta monkey) in the experimental tolerance of 13 hepatic artery ligation, and do not have antibiotic treatment. Thus these studies to block the hepatic portal Pringle security applications laid a theoretical basis.
  always practical needs of theoretical research is the most powerful stimulus agent in liver surgery, the surgeon needs to the internal anatomy of the liver have a better understanding. 1951 Swiss Hjortsj [1] established the first liver specimens pipeline corrosion and mold cholangiography research methods, after 10 cases observed by the hepatic artery and hepatolithiasis showed segmental distribution, and the liver is divided into inner and outer, after ago, a total of five of the tail. Later, Healey and Schroy [2] The study also confirmed Hjortsj further discovery in the distribution of intrahepatic portal vein is the same, and in accordance with the normal anatomy of the liver naming principle subparagraph naming system. Couinaud hepatic vein from the distribution function of the liver by subparagraph [3]. Anatomic study results show that the liver is a sub genitals, each has its liver of a separate pipeline system can be used as a surgical resection units. Anatomy of the liver, which in turn also urged Progressive development of the liver surgery. Internally, the Shanghai Second Military Medical University in the 1950s, Miss Mengchaodeng liver when the anatomical study.
  50 in the mid - when, Goldsmith and Woodburne [4] stressed liver resection of the liver should be strictly complied with the internal anatomy, have proposed the rules of the liver resection of the concept of (regular hepatic lobectomy). In the late 1950s, Quattlebaum and Quattlebaum [5] stressed that the extensive liver resection surgery elements, including: fully reveal, hepatic vascular occlusion, completely free liver, blunt object isolated hepatic parenchyma. Such treatment is still views importance.
  regardless of how you familiar with the anatomy of the liver, liver, but always open bleeding, how to reduce the loss of blood, liver, cut macrovascular not collision, which is the consensus. Quattlebaums stand off with a blunt object to the liver, but this concept has already seen early liver surgery. Various to blunt the main fault intrahepatic vascular liver preservation methods were used, such as has been recommended by a nail, Tong That Tung (Hanoi, Vietnam) in liver blood flow control blunt broken liver, Oglivie with vascular Clamp, Quattlebaum with surgical knife handle, Lintianyou (China Taiwan) fingers rubbed liver tissue, is now also used by the technique (finger fracture technique) [6]. The past 10 years and there used to reduce vascular hemorrhage broken liver specialized equipment, such as the most widely used "ultrasonic scalpel" (CUSA), In addition, there was still "water knife" [7], Peng Shuyou "including suction knife" in Renzhong "suction Cutter." The section on using bleeding in the liver while bleeding electrocoagulation with high frequency, infrared coagulation hemostasis, argon beam, "laser sword", plasma cutter, microwave hemostasis, various forms of liver clamp, liver tourniquet, and other equipment and tools; Drugs are like absorbable hemostatic fiber, fibrinogen , prothrombin, the collagen protein, macromolecular polymers products and this can be "spectacular", these new methods of hemostasis there is always accompanied by the development of liver surgery, in which development has not yet ended.
  Une [8] compared the "Water Knife" (Water Jet Disector) and "ultrasonic scalpel" (Cavitron Ultrasonic Surgical Disector, CUSA) in a total of 68 cases of liver resection in patients using the advantages and disadvantages that, in the liver, cutting the blood loss, operation time, the two are not prescribed significant differences, but feel "water knife" will be organized by litter wash, and it could be more clear surgical field, in patients with cirrhosis, the liver also easy to cut, and the merit of equipment cheaper and easier maintenance of the use of safety, so that "water knife" as "ultrasonic scalpel" alternative supplies . The liquid is used saline. But the Chinese University of Hong Kong Liuyongyi professor in the discussion that "water knife" Although there is clearly more to the surgical field, but high-pressure water column splash can be formed by particulate pollution threat to the environment and the operating room staff, because of liver cancer patients have hepatitis B or hepatitis C virus infection, the other, there had been "water knife "tangential liver air embolism occurred when the report. Rau [9] cut to reduce the loss of blood when the liver, to become hypertonic saline brine to enhance their conductive properties, and water cannon installed on the high-frequency current, can be activated at any time hemostatic coagulation effect, does not require the replacement of equipment in order to save time.
Hepatic ischemia time tolerance 3
  block in the hepatic portal surgery can not bleeding, but the hepatic vascular occlusion can last long?
  Dong Jiahong [10] experiments with rats, to avoid blocking of the portal vein blood stasis to prove that rats can be safely blocked for 90 min, then clinically? Clinical Practice has proved that a large number of block hours in the hepatic portal within 15-20 min is safe, but for the wider and the complex liver surgery, this time within the limits of safety inevitably too short, so many 20 min 5-10 min interval blocking the blood flow open from clinical practice has proved to be effective. Elias [11] in 112 cases of hepatic resection of liver cancer patients, 20 cases of blocking the cumulative time over 90 min (mean 109 min), and each block is not sustained over 20 minutes, in which two cases of liver resection (IV, V, VIII segments) complex surgery , two cases of clamping time more than 140 min. Results after 20 cases without surgery died within 30 days, after the operation liver function changes are not significant differences. Elias repeatedly that the intermittent hepatic portal can be used to block abnormal hepatic parenchyma (often have hepatic artery embolization after chemotherapy), in hepatectomy broad cross-section of liver, surgery to reduce blood loss.
  graded block hepatic blood flow Although it is safe, but the restoration of blood flow in each when it is inevitably increased blood loss. Whether the human liver can tolerate a long ischemic time? The previous time limit is only 15 minutes from the dog's information derived from the experiment, such as the Child by the different species of animals tolerance clamping time very different. Some of the reported hepatic portal block (portal triad clamping, PTC) or hepatic vascular isolation (hepatic vascular exc Lusion, HVE) security can be achieved time 60 min.
4 hepatic vascular occlusion in total hepatic vascular isolation
  Heaney (1966) first proposed total hepatic vascular isolation (total hepatic vascular exclusion) of the purposes of liver resection of the concept [12]. Surgery clamp porta hepatis, liver, the liver of the inferior vena cava, while occlusion of the abdominal aorta. Huguet 1978 years using this method, which include liver cirrhosis patients with liver cancer, but surgical mortality rates higher, up to 28% (in patients with liver cirrhosis). Bismuth [13] (1989) this method has been applied to 5 One case of the patient, the surgical mortality rate dropped to 20%, the average time hepatic vascular occlusion is less than 50 min (46.5 min), and saw no need for occlusion of the abdominal aorta, not for cirrhosis patients. The low temperature liver perfusion (Fortner, 1974 advocates) is not necessary, because the process of surgery will naturally lower body temperature, and sometimes it drop too low, so Huguet used in the operation to control the temperature blankets. Thereafter total hepatic vascular isolation methods to cut liver The multi-use.
  Huguet (1992) pointed out that although the liver resection is now widely used, but when the huge tumor in the liver or near the Central Department of inferior vena cava and hepatic vein, the general should not use conventional methods of surgical resection or great danger of . Conventional surgery is the main danger may be torn liver after the inferior vena cava or hepatic vein in massive loss of blood and air embolism. Hepatic vascular isolation can prevent this complication. The main points of hepatic vascular isolation is indeed under the control of the peritoneal cavity after intravenous branch. Emre [14] (1992) with total hepatic vascular isolation of liver for the treatment of 16 cases of patients with liver tumors huge, the average tumor diameter of 10.7 cm, the outcome of two cases of death, the author stresses must complete vascular isolation in the porta hepatis many small collateral vessels if not completely block still will cut more of the liver, bleeding, and even blocking blood loss were greater than not, the use of noninvasive vascular wide to block clamp liver duodenal ligament more effective.
  Huguet [15,16] method is in the supine patients, the use of blankets to avoid hypothermia, bilateral long incision under the rib edge along the center line extending upward from cream, if large tumor size, the upper and lower vena cava revealed liver problems, while the right side of No. 7 or 8 intercostal incision more appropriate, and fully free of the liver ligament and adhesive is an important step in this procedure. Block liver duodenal ligament, should pay attention to whether ectopic left hepatic artery (from the left gastric artery); Under hepatic inferior vena cava in high blocker, should be in the right adrenal vein into the inferior vena cava above plane; The liver separation clearly superior vena cava, bypassing a sling, when a huge tumor, liver revealed after the inferior vena cava wall is often difficult. Therefore, this right thoraco-abdominal incision helpful. Next on the inferior vena cava, the two bleeding beneath the clamp Commissioner clamp most important, to request two clamp Tsim rounded to the inferior vena cava blood flow will be isolated. Do not cut liver before hepatic portal anatomy, but to reduce the clamping time, we and the author advocated some domestic anatomy of the hepatic portal first, the final steps on the block [17,18]. Huguet in 53 cases of liver resection patients using continuous block approach, compared blocked for more than one hour in 15 cases and blocked for 1 h following, not long after blocking opponents mortality and complication rates, changes in liver function between any obvious implications, will author liver ischemic tolerance time there limit? Hannoun [19] (1993) of 34 cases of patients underwent extensive surgical resection of the liver in a liver blocked blood flow sustained more than 60 min retrospective analysis, of which 15 cases at the same time blocking the liver and hepatic inferior vena cava, to prevent intraoperative hypothermia, the result of a continuous block, an average of between 73.6 minutes, the longest blocking one cases of 127 min, surgery difficult because the relationship between the body temperature of patients in an average of 35 ° C after liver dysfunction and no significant block of time, not one case of the whole group after surgery died within 30 days. Thus Hannoun come to the conclusion that in the absence of cirrhosis patients, can be a continuous block of time to 90 min; However, if the estimated time to block 120 min, suggested UW (University of Wisconsin) of cryogenic preservation of liver perfusion.
5 vitro Hepatectomy
  with liver transplantation and in vitro technologies mature kidney surgery Enlightenment, the Hanover, Germany Pichlmayr [20] began in 1988 when the first cases were Fortner [21] in vitro perfusion of the liver cooling liver resection, the desire to achieve a more thorough tumor resection and removal in some patients with liver transplantation , to 1990, has done 11 cases of surgery. When fashion is a preliminary report, which it is difficult to comment on the significance of surgery, but the report has revealed that all patients with jaundice (a total of four cases) do not have good results, a surgical failure, and liver tumors (liver metastases) will have some effect. Cooling under in vitro perfusion of the liver resection technically demanding than orthotopic liver resection more complex, so can be used in complete surgical excision methods, generally do not choose in vitro resection.
  in vitro liver resection because of their own liver replantation and the complex technical and time-consuming, France Sauvanet [22] (1994) to simplify the isolated liver surgery. The main points of this operation is not cut off hepatic portal pipeline structure, within the portal vein catheter inserted hypothermic perfusion, portal - IVC in vitro blood flow to the liver separation from top to bottom IVC pericardial sentenced Lee to re-anastomosis, the upper and lower cut off liver inferior vena cava and hepatic inferior vena cava under when the two ends will be cut off inferior vena cava, then liver in vitro can be moved out (the only gate structure Linked), the general method to resection of the tumor resection difficult. Author done five cases received better results. To further simplify operation, but was designed to address invasive liver after liver vein and inferior vena cava resection of the tumor, Hannoun's isolated position (Ex-situ In-vivo) of the liver resection. Domestic Dong Jiahong [23] (1996) with total hepatic blood flow and cooling to the semi-vitro perfusion of the liver in the treatment of transgression and the inferior vena cava and hepatic veins of the right of hepatocellular carcinoma, the patients have mild liver cirrhosis, had surgery after a transient liver dysfunction.
6 cirrhosis of the liver, blocking blood flow
  liver cirrhosis at the time of vascular isolation cooling and liver perfusion can lead to increased liver cell damage adverse results, even in patients with obstructive jaundice, the same result is disappointing, therefore obvious obstructive jaundice and cirrhosis are considered hepatic portal blocked for a long time taboo. A large number of facts have proven that in the hepatic portal blocking limit within 15-20 min, the recovery of surgical patients there was no apparent impact, and the more time blocking and blocking the limits, have not yet been resolved. Orient primary liver cancer often associated with cirrhosis, 85% of China's primary liver cancer with cirrhosis, hepatitis and mostly after cirrhosis, total hepatic injury obviously universal, with obvious liver fibrosis and sometimes partial liver atrophy, portal hypertension and decompensated hepatic arterial blood flow increased, broken surgery when liver bleeding than normal liver tissue. So when cirrhosis of the liver blocked blood flow in China's more special significance.
  vascular isolation of the liver can reduce undoubtedly the rules of non-cirrhotic liver resection and postoperative bleeding complications, the current is more of this surgery to stop bleeding in the microwave coagulation under implementation of effective good, but sometimes smaller because of tumor blood vessels and adjacent important, bile duct, the separation must need surgery resection. Japan Nagasue [24] (1985) Comparison of the three groups or liver resection of liver patients: not blocking (17 cases), Pringle blocker (19 cases), liver inflow and outflow channel blocker (11 cases) the results of the latter is in Pringle blocking in addition to any incision falciform ligament liver and crown ligament, isolated from the side of the hepatic vein surgery were to be blocked and not block the inferior vena cava, the longest time 47 min block, the results of the third group were bleeding decreased significantly compared with the former, no operative deaths, the complication rate also decreased significantly. However, isolated hepatic vein and hepatic vein were blocking is not easy, it is still not widely used.
  Pringle vascular occlusion reduce the scope of influence, is also against cirrhosis resection of the measures proposed. Japan Makuuchi [25] (1987) suggested that liver cirrhosis of liver resection of vascular occlusion half when the safety of this method in the country have been Huaxi Medical University Guang Zheng Qi, Yan Lunan, etc. and our extensive use of this can withstand the liver tissue from the contralateral ischemic damage. Half of hepatic vascular occlusion method is simple and easy [26-28]. The doors of the system in the intrahepatic course is wrapped in fiber intrathecal Glisson, all liver independent of the formation of a liver, biliary vascular pedicle, or Gate of triple (portal triad) but this triple pipelines (especially Couinaud Ⅶ, Ⅷ liver) is not easy to find the building in the liver, which is not easy from the hepatic portal the Department of fiber sheath, the anatomy of the liver was found. However, the use of intrahepatic channels (intrahepatic approach), can be more easily separated from the fibrous sheath of the liver bile duct of the vascular pedicle and the respective control, the method called intrahepatic fiber sheath diameter Road (intrahepatic extrafacial approach), or known as the intrahepatic after Pathfinder (posterior intrahepatic approach) [29], its high biliary stricture repair and hilar cholangiocarcinoma surgery often be applied. Open surgery is the right caudate process and the liver parenchyma of the liver and liver capsule on the door edge of the liver capsule, liver door along the deep-Blunt (commonly used finger separation) separation, it can be fibrous sheath, in separation of the second stage of the liver and gallbladder bile duct vascular pedicle and were home to tape or clamp block. However, the Japanese Gotoh [30] relatively selective hepatic portal blocker (n = 13) and blocked hepatic portal liver (n = 8) cirrhosis of the liver cancer patients of liver surgery at the reaction results in the latter than the former operative time and blood loss were significantly reduced in that paragraph liver hepatic pedicle blocking their surgery complicated, there has been no obvious advantages.
  at low temperature can be extended liver cells hypoxia tolerance time. Cirrhosis, if additional cooling treatment, it is possible to strengthen the liver cells to hypoxia tolerance. Yamanaka [31] in 50 cases of hepatocellular carcinoma right lobe of the liver cirrhosis of the liver resection, compared normothermic liver and liver vascular occlusion of vascular occlusion additional cooling vents partial results, there was no significant difference between the two groups, although the cooling group clamping time significantly longer; Yamanaka and that the liver under local cooling Ye vascular occlusion time could be extended to 60-90 min. Time is expected to block the blood flow of up to 30 minutes or more, should be supplemented by using partial hepatectomy blocking cooling more appropriate.
7 hepatectomy technology development
  liver surgery is actually surgical anatomy of the liver and the combination, when surgeons understand the anatomy of the liver after liver surgery will be rapid development in the 50-60 age, liver resection have been standardized, the more practices, rules of liver resection (regular hepatic lobectomy ), that is, first of all deal with hepatic portal from the liver and the hepatic vascular and liver resection in real terms. This method has been contained in the general teaching, in spite of the author also certain technical amendments. 1952 Lortat-Jacob, Quattlebaum 1953 Pack and the rules of hepatectomy laid a foundation for liver surgery, Europe and the United States for metastatic liver tumors without cirrhosis, so this has been along the way, so Schwartz [32] published in 1984 resection of the right lobe of the liver; Starzl [ 33] (1980) by the expansion of right lobe of the liver resection or three paragraphs called resection of the right (right hepatic trisegmentectomy) at current commonly used method; However, in liver resection of the left side of the expansion, Starzl [34] published by the three resection of the left (left hepatic trisegmentectomy) surgical methods , are still not perfect enough, the blood loss surgery and postoperative complication rates were higher, remains to be desired. Expand the left hepatic lobe, the largest technical difficulties in the isolated liver parenchyma should strictly follow the right hepatic crack (right hepatic fissure) plane, and this fissure in the liver liver It is also not obvious on the surface, it is V, VIII and VI of the liver, liver Ⅶ paragraph of the sub-interface, thus if there are deviations from surgery, , it may be right hepatic vein injury, in particular the right posterior segment of the liver caused very difficult situation. Huguet [35] (1994) with hepatic vascular isolation method left hepatic resection of leaf expansion in the hepatic vascular isolation, in the case of blood along the right hepatic vein to the distal separation surgery at the end, we could clearly see the right hepatic vein on the following firms liver section. Huguet 8 patients with vascular isolation time for 58-85 min, an average of 70 minutes, without surgery within 30 days after death, but one died after the first 40 days, one case of 17 days postoperative hemorrhage and hepatic coma due to acute liver transplantation purposes, and left another one case of biliary fistulas. Thus, the left hepatic resection of leaves to the current expansion is still doing the surgery and rarely has a high complication rate, the use of "ultrasonic scalpel" isolated hepatic parenchyma, it is possible to reduce the operation of vessels and bile duct injury. The left hepatic resection of leaf expansion (left three resection) technical problems remain to be perfect.
  liver cancer in China is a big country "," many patients, liver surgery has been very active. During the 1950s, Beijing and Guangzhou Cheng - En Wang Professor Professor ZENG Xian - nine representatives has accumulated more than 50 cases of hepatocellular carcinoma of the liver resection of the rules of the experience, but a higher surgical mortality, then experience is summed up by: (1), liver cancer with cirrhosis of the liver resection should be <50%; ( 2) extensive liver resection should be very careful; (3) liver failure is the leading cause of death surgery; (4) Long-term treatment with hepatic resection seems disproportionate amount; (5) cirrhotic patients should be more conservative hepatectomy. 50-60 in the period, Wu Mengchao, Professor liver [36,37] committed to the research and development of the anatomy of the hepatic portal blocking the liver surgery, Up to today, and accumulated the world's largest series of cases of liver cancer resection. 1971 in the then "beat cancer three years" under the call, et al [38] Professor of AFP in the early diagnosis of liver cancer, "tailor" type of liver resection, liver cancer surgical treatment of a breakthrough, and the development of China and even in Asia to become the surgical treatment of liver cancer model.
  liver bleeding problems, like anatomy of the liver surgery in the clinical interpretation, it is surgery technological changes over the years is not great until the liver surgeon noted that the caudate lobe of the liver. Since anatomical location, liver caudate lobe resection of the tumor is still liver surgery has been the "forbidden zone." The purposes of the past once the liver caudate lobe resection of the liver together with most of the left, right lobe of the liver or hilar biliary additional surgery, not yet finalized their separate liver caudate lobe resection (isolated hepatic caudate labectomy). For example, Elias [39] 212 cases of malignant tumor resection of the liver, only one case of as separate the caudate lobe resection. In fact, the caudate lobe of benign and malignant tumors are not rare.
  Yammamoto [40] (1992) report one case of caudate lobe tumor left by separation, at the junction of the former approach right liver lobe (anterior approach) Act resection; Later, Yamamoto [41] reported five cases separate caudate lobe resection, four cases of hepatocellular carcinoma, and one case of colon cancer metastasis after more than four years are to survive, the surgical method is used separately liver median cleft of the former approach, the right hepatic surgery will be free to cut off the inferior vena cava vein short before the liver, isolated right hepatic vein; Free liver to the left outer leaves, cut off and left hepatic vein ligament connecting vein, caudate lobe static from the inferior vena vein Isolation, isolated left hepatic vein in the liver, and around the block with. Subglottic in blocking the liver through the hepatic vein in the liver left off, will be adjacent to inferior vena cava (paracaval) part of the caudate lobe from the liver door separating the cut caudate lobe of the liver and portal branches in the vein until the rear, separated from the right caudate process with the attachment and liver resection of the entire caudate lobe tumor. Yamamoto separate road that before the caudate lobe resection of the liver although not so commonly used, but still have cirrhosis can consider as a curative surgery. Domestic Peng Shuyou resection with six cases before the Pathfinder caudate lobe tumor. Colona [42] (1993) with the left channel with two cases of liver metastases and one case of nodular hyperplasia; After Lerut approach (posterior approach) with one case of caudate lobe tumors but not very successful, as required bleeding gauze packing. Huang [43] The left - right - left a joint approach (left-right-left combined approach) with three cases of primary caudate lobe tumor. Bartlett [44] and their colleagues report four cases of separate caudate lobe resection is the former approach, and through the implementation of bilateral approach, the author之一Blumgart paper also recognized that the bilateral approach in accordance with the principle of liver resection caudate lobe resection is feasible without the necessary liver parenchyma. Facts have proven that separate caudate lobe resection of liver surgery is no longer a "forbidden zone" [45] However, the author also proposed a separate caudate lobe resection in the treatment of primary liver cancer, is reasonable. Nagasue [46] reported six cases of primary liver cancer in the caudate lobe caudate lobe resection alone the long-term effect, determine its efficacy in line with other parts of primary liver cancer resection. Therefore, separate caudate lobe resection for the caudate lobe of primary and secondary tumors is feasible and reasonable, especially when combined with cirrhosis when.