Bimanual 'bi-finger' liver hanging maneuver: an alternative and safe technique for liver hanging

Background. Currently, a popular method for right hepatectomy is hepatic resection with the liver hanging maneuver. The aim of this study is to present an alternative and safe approach during this maneuver without using any instrument, thus avoiding injury. Patients and methods. From March 2005 to April 2006, a bimanual 'bi-finger' liver hanging maneuver (BBLHM) was planned in 22 right hepatectomies and the data were collected prospectively after operation. Results. BBLHM was performed in 21/22 patients (95%). The maneuver was stopped in one patient, due to manual detection of an accessory hepatic vein during finger dissection in the retrohepatic space. This vein did not allow completion of the BBLHM. The indications for right hepatectomy included 11 primary hepatic tumors (52%), 8 metastatic right hepatic tumors (38%), and 2 hydatid cysts (9%). Intraoperative ultrasound (IOUS) demonstrated the normal anatomical configuration type of the hepatic veins. Bleeding occurred in one patient (4%), which was interrupted with the use of continuous 6/0 polypropylene suture. Discussion. The most important step during the liver hanging maneuver is to develop the avascular space without any complication. In the present study, the index fingers were used instead of forceps during the blind dissection. BBLHM not only reduced the rate of damage to the hepatic veins but was also predictive for the presence of any accessory vein by its manual detection prior to injury. This maneuver allowed easier clamping of the hepatic veins and controllable hepatic resection. Dissection of retrohepatic space with the BBLHM produces a safer method, using both index fingers instead of a surgical instrument.