Intraoperative doppler ultrasonography to assess the need for remnant liver fixation

Hepatic venous outflow block (HVOB) is a potentially serious complication after hepatectomy. Although routine anatomical fixation of the remnant liver is often advocated to prevent HVOB, its universal necessity remains controversial. We conducted this study to evaluate the utility of intraoperative Doppler ultrasonography for guiding selective remnant liver fixation.

A total of 26 patients who underwent right-sided or central hepatectomy with transection of the falciform ligament between April 2016 and January 2025 were enrolled prospectively in this study. Intraoperative Doppler ultrasonography was used to assess venous flow in spontaneous and anatomical liver positions. Fixation using the round ligament, with or without the falciform ligament, was performed selectively when venous outflow impairment was observed.

Eight patients (31%) required fixation. Portal vein thrombosis occurred in five patients, including one with concurrent hepatic vein thrombosis caused by incorrect positioning. Apart from the illustrative case, all thrombotic events were asymptomatic and resolved with anticoagulation. Postoperative complications and liver regeneration were comparable between the groups. Postoperative abdominal discomfort was more frequent in the anatomical group, but the difference was not significant.

Intraoperative Doppler ultrasonography may facilitate on-demand remnant liver fixation by allowing real-time assessment of venous outflow impairment. This approach may help prevent complications and avoid unnecessary fixation.