S4a + $5 With Caudate Lobe (S 1) Resection Using the Taj Mahal Liver Parenchymal Resection for Carcinoma of the Biliary Tract Yoshifumi Kawarada, M.D., EA. C.S., Shuji Isaji, M.D., Hiroki Taoka,M.D., Masami Tabata, M.D., Bidhan Chandra Das, M.B.B.S., Hajime Yokoi,M.D. Recently we have been performing S4a + $5 with total resection of the caudate lobe ($1) by using a dome-like dissection along the root of the middle hepatic vein at the pinnacle, which we refer to as the Taj Mahal liver parenchymal resection, for carcinoma of the biliary tract. This procedure offers the fol- lowing advantages: (1) It allows total resection of the caudate lobe, including the paracaval portion ($9), and (2) because the cut surface of the liver is large, it allows intrahepatic jejunostomy to be performed more easily with a good field of view. The indications for this procedure include hilar bile duct carci- noma, gallbladder carcinoma, and choledochal cyst (type IVA). Because of the high rate of hilar liver parenchyma and caudate lobe invasion associated with hilar bile duct carcinoma, the liver must be re- sected. The Taj Mahal procedure is indicated in cases where extended liver resection is impossible. The dissection limits of this procedure are, on the left side, the B2 + 3 bifurcation at the right margin of the umbilical portion of the portal vein and, on the right side, the B8 of the anterior branch and the B6+7 bifurcation of the right posterior branch. This procedure could also be described as a reduced form of ex- tended right hepatectomy and extended left hepatectomy. For gallbladder carcinoma, this procedure is in- dicated to ensure an adequate surgical margin and eradicate transvenous liver metastasis, particularly in cases ofpT2 lesions. Hilar and caudate lobe invasion also occurs in liver bed-type gallbladder carcinoma, and bile duct resection and caudate lobe resection are required for the surgery to be curative. We per- formed this procedure in four cases ofhilar bile duct carcinoma, five cases of gallbladder carcinoma, and one case each of choledochal cyst (type IVA) with carcinoma of the bile duct and gallbladder adenomy- omatosis. Curative resection was possible in all except the patient with adenomyomatosis, and all of the patients are alive and recurrence free 10 to 37 months postoperatively. This procedure, in addition to preserving liver function, provides a wide field of view and facilitates reconstruction of multiple intra- hepatic bile ducts. Thus it can be said to be a curative operation not only in patients considered high risk but also in those whose hilar bile duct carcinoma is limited to the bifurcation area (Bismuth type Ilia and IIIb) and in gallbladder carcinoma up to pT2 with slight extension on the hepatic side. (J GASTROINTEST SURG 1999;3:369-373.) KEY WORDS: Biliary tract carcinoma, Taj Mahal liver resection, surgical technique, curative resection Major hepatic resection is currently being per- formed in Japan as curative treatment for bile duct carcinoma and gallbladder carcinoma. 1 However, when extended resection is performed to treat these carcinomas, the volume of remnant liver parenchyma is very small, and as a result postoperative hepatic in- sufficiency and hepatic failure are not infrequent. A1- though many surgeons are performing preoperative portal vein embolization for hypertrophy of the rem- nant liver, 2,3 the incidence of complications after such operations remains quite high. 1,4 Reports from other countries have also shown high morbidity and mor- tality rates after hepatic resection for biliary tract carcinoma.5, 6 In hopes of resolving this dilemma, we From the First Department of Surgery, Mie University School of Medicine, Tsu, Mie, Japan. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17-20, 1998 (poster presentation). Reprint requests: Yoshifumi Kawarada, M.D., F.A.C.S., First Department of Surgery, Mie University School of Medicine, Tsu, Mie 514- 8507, Japan. 369