Right-sided retrocaval approach using guidance via the lesser sac for Spieghel lobe resection

Background: Few reports describe technical problems encountered in resections of the Spieghel lobe of the liver.

Methods: The relationship of the caudate lobe with the inferior vena cava (IVC) was analyzed using computed tomography in 51 patients without hepatobiliary diseases. Using reconstructed 1 mm axial images, the angles of the most dorsal part of the Spieghel lobe (angle A) and the right hepatic lobe (angle B) around the IVC were measured clockwise from the ventral midpoint of the IVC.

Results: In 11 (22%) patients, angle A was 180 ° or more, thus the retrocaval part of the Spieghel lobe projected rightward beyond the dorsal midline, but in 1 patient (2%) the right dorsal part of the liver extended leftward beyond the dorsal midline. In 20 (39%) patients, angle A was less than 135 degrees. The Spieghel lobe surrounded the IVC most dorsally at 22% of the distance from the top of the retrohepatic IVC. In 9 patients (18%), the retrocaval process of the Spieghel lobe appeared to be connected to the dorsal part of the right lobe.

Conclusion: The Spieghel lobe sometimes extends to the right, dorsal aspect of the IVC, such that a right-sided approach facilitates securing the retrohepatic IVC through the lesser sac and allows a safe dissection of the protruding portion of this lobe.