Left hepatic trisectionectomy for perihilar cholangiocarcinoma with a right-sided round ligament: A case report

Figure 1 Computed tomography images of the patient. A: The wall of the biliary trees was thickened at the confluence of the left and right hepatic ducts (white arrowhead). The yellow dotted line indicates the boundary between the anterior and posterior sections; B: The anterior branches of the portal vein (Pant, yellow arrows) diverged from the right-sided umbilical portion (blue arrowhead); C: The round ligament (black arrowhead) was attached to the right-sided umbilical portion; D: The left portal vein (LPV, blue arrow) ramified at the hepatic hilum. The middle hepatic vein (MHV) was observed between the LPV and Pant; E: The posterior branch of the portal vein ramified independently (Ppost-i type, black arrow), and the round ligament was located on the right side of the gallbladder (black arrowhead); F: A three-dimensional image of the portal vein clearly illustrated the independent ramification of the posterior branch (Ppost-i, black arrow) from the main portal vein. RHV: Right hepatic veins; MHV: Middle hepatic vein; GB: Gallbladder.

Figure 2 Endoscopic retrograde cholangiography revealed the severe stenosis of the hilar bile duct (yellow arrow). The stenotic portion extended from the hepatic hilum to the right, B2, and B3 bile ducts (white arrowheads).

Figure 3 Operative findings. A: The gallbladder was located on the left side of the round ligament; B: The hepatic hilum was dissected, and the vessels were encircled by tape. The course of the right posterior hepatic artery was infraportal; C: After division of the left hepatic artery, right anterior hepatic artery, left portal vein and right anterior portal vein, the resection line of the liver was marked along the demarcation line on the liver surface; D: The cutting surface after left trisectionectomy and caudate lobectomy. Liver resection was conducted along the right hepatic vein. PV: Portal vein; LPV: Left portal vein; GB: Gallbladder.

Figure 4 A three-dimensional image analysis software system was used to confirm the liver volumetry. These images represent case 1 and case 6 in Table 1.