Selection of Appropriate Liver Resection in Left Hepatolithiasis Based on Anatomic and Clinical Study Seung Eun Lee Æ Jin-Young Jang Æ Jeong Min Lee Æ Sun-Whe Kim Published online: 16 January 2008 Ó Socie ´te ´ Internationale de Chirurgie 2007 Abstract Background Because of the possibility of injury to the left medial section of the bile duct (B4) and the presumed higher recurrence rate of hepatolithiasis, some surgeons have recently preferred left hepatectomy for left hepatoli- thiasis. We investigated the appropriate treatment for left hepatolithiasis by evaluating the anatomy and variations of the left hepatic duct system in a normal population and analyzed the clinical outcome of liver resection. Methods We reviewed the magnetic resonance imaging results of 115 normal subjects who underwent a workup for living related liver donation. An imaginary surgical resection line was established based on the lateral margin of the umbilical portion of the liver in T2-weighted axial images. The junction of B4 with the left hepatic duct was evaluated to determine the possibility of injury during liver resection. We also analyzed the clinical outcomes of 181 patients who underwent left lateral sectionectomy or left hepatectomy. Results The anatomic evaluation showed that B4 joined lateral to the umbilical portion of the liver in 7.0% (8/115) of cases. In patients with left hepatolithiasis, left hepatec- tomy was performed in 79 patients and left lateral sectionectomy in 102. The operating time for the left lateral sectionectomy was significantly shorter than that for left hepatectomy (p = 0.001). There were no significant dif- ferences in complications or recurrence of stones. Conclusion Preoperative cholangiography should be performed to evaluate the anatomy of the left hepatic duct to avoid injuring B4. For most cases of left hepatolithiasis without a left hilar stricture, left lateral sectionectomy is the safest, most effective treatment. Hepatolithiasis is a common disease in Southeast Asia, where it is more common than in Western countries. Although life style, including dietary habits and the envi- ronment, has become increasingly westernized in Korea [1], the incidence of hepatolithiasis has remained the same [2]. Hepatolithiasis most commonly affects the left hepa- tobiliary system. This is because the left hepatic duct has a more acute angle than the right hepatic duct [3]. The left lateral section of the liver is the most commonly involved site [4]; therefore left lateral sectionectomy is routinely performed [5, 6]. Recently, however, left hepatectomy has been recommended by some authors [7, 8]. Concerns have been raised about injury to the left medial section of the hepatic duct (B4) during left lateral sectionectomy. These concerns are based on accumulating knowledge and experience. Onishi et al. [7] analyzed 171 specimens from 71 adult cadavers and 100 liver casts and reported that in 24% of patients the left medial section of the hepatic duct comes from the B3 duct. They suggested that B4 could be injured during left lateral sectionectomy. Sun et al. [8] reported that in a comparison of two groups who under- went left hepatectomy or left lateral sectionectomy there S. E. Lee Á J.-Y. Jang (&) Á S.-W. Kim Department of Surgery, Seoul National University College of Medicine, 28 Yeongeon-dong, Jongno-gu, Seoul 110-744, Korea e-mail: jangjy4@snu.ac.kr S. E. Lee e-mail: selee508@medimail.co.kr J. M. Lee Department of Radiology, Seoul National University College of Medicine, 28 Yeongeon-dong, Jongno-gu, Seoul 110-744, Korea 123 World J Surg (2008) 32:413–418 DOI 10.1007/s00268-007-9355-1