A trisegmentectomy is one of the largest liver operations a surgeon can perform, removing roughly 70 to 80 percent of the organ in a single procedure. In the most common version, a right trisegmentectomy, the surgeon takes out the entire right lobe of the liver along with a sizable portion of the left lobe, leaving behind only two small segments to keep the patient alive while the liver regrows. The operation exists because the liver is uniquely capable of regenerating, and because some tumors are too large or too centrally located for a smaller resection to clear the disease. That regenerative capacity is remarkable, but the surgery itself pushes it to its limits, making preoperative planning, intraoperative technique, and postoperative monitoring all critical to survival.
What the Name Actually Means
The terminology around major liver resections is notoriously confusing, and trisegmentectomy is a prime example. The term comes from an older North American naming system that divided the liver into four “segments” based on the major hepatic veins, so removing three of those four segments was a “trisegmentectomy.” In 2000, an international consensus meeting in Brisbane attempted to standardize the language. That system, now widely adopted, calls the same operation a “trisectionectomy” or an “extended hepatectomy.”1HPB. The Brisbane 2000 Terminology of Liver Anatomy and Resections You will encounter all three terms in surgical literature and hospital consent forms, and they all describe the same basic procedure. A right trisectionectomy removes segments 4 through 8 (and sometimes segment 1), while a left trisectionectomy removes segments 2 through 5 plus segment 8. The right-sided version is far more common because the right lobe is larger and more frequently harbors tumors that require extended clearance.
When Surgeons Recommend It
The most frequent reason for a trisegmentectomy is cancer. Primary liver cancers such as hepatocellular carcinoma and cholangiocarcinoma, as well as cancers that have spread to the liver from the colon or other organs, can grow large enough or involve enough of the liver’s internal blood supply that only an extended resection can remove all the disease. In one institutional series, 52 patients underwent left trisectionectomy for hepatocellular carcinoma, cholangiocarcinoma, hilar cholangiocarcinoma, or colorectal metastases, and their survival was comparable to what had been reported after less extensive resections for the same tumor types.2PubMed. Left hepatic trisectionectomy for hepatobiliary malignancies That finding is significant: it suggests the operation, despite its size, does not inherently carry worse long-term outcomes than a smaller one when the indication is right.
Hilar cholangiocarcinoma, a cancer arising where the bile ducts branch inside the liver, is one of the most challenging indications. Achieving negative margins often demands not just a trisectionectomy but also removal of the caudate lobe and reconstruction of the bile ducts, a technically demanding combination that remains difficult even for experienced hepatobiliary surgeons.3PubMed Central. Right hepatic trisectionectomy combined total caudate lobectomy with non-touch technique for advanced hilar cholangiocarcinoma A smaller number of trisegmentectomies are done for benign lesions, such as large hemangiomas or hepatic adenomas that cause symptoms or carry a risk of rupture. In an early series of 30 right trisegmentectomies, four were performed for benign disease.4PubMed Central. Right trisegmentectomy for hepatic neoplasms
Making Sure Enough Liver Is Left Behind
The central concern with any trisegmentectomy is whether the small piece of liver that remains, known as the future liver remnant, will be large enough and healthy enough to keep the patient alive while the organ regenerates. If it is not, the patient develops post-hepatectomy liver failure, the leading cause of death after major liver resection.5PubMed Central. Risk factors for post-hepatectomy liver failure in 80 patients Measuring the remnant starts with imaging. CT or MRI scans allow surgeons to calculate the volume of the segments that will remain, typically expressed as a ratio of remnant volume to the patient’s total estimated liver volume based on body surface area.6PubMed. Standardized measurement of the future liver remnant prior to extended liver resection: methodology and clinical associations
Volume alone does not tell the full story, though. A liver damaged by chemotherapy, fatty liver disease, or cirrhosis may look adequate on a scan but function poorly. Some centers use nuclear medicine scans to assess actual liver function alongside volume. One approach multiplies the volumetric remnant percentage by a measure of total liver clearance obtained through a tracer scan, producing an estimate of the remnant’s functional capacity.7PubMed Central. Future remnant liver function estimated by combining liver volumetry on magnetic resonance imaging with total liver function on 99mTc-mebrofenin hepatobiliary scintigraphy More recently, researchers have explored whether the ratio of remnant volume to body weight is a better predictor of post-hepatectomy failure than the traditional volume-to-total-liver ratio, particularly in patients at different ends of the body-mass spectrum.8PubMed Central. Appropriate methods of evaluating future liver remnant volume to predict postoperative liver failure after major hepatectomy based on the body mass of patients with normal hepatic reserve No single metric is perfect, and most high-volume centers use a combination of volume measurements and functional tests before committing to a trisegmentectomy.
Growing the Remnant Before Surgery
When the future liver remnant is too small, the operation is not necessarily abandoned. Instead, surgeons can coax the remnant to grow before the resection, a process called preoperative liver augmentation. The standard method is portal vein embolization, in which an interventional radiologist blocks the portal vein branches feeding the side of the liver that will be removed. This redirects blood flow to the remnant, stimulating it to enlarge over several weeks.9PubMed Central. Portal vein embolization failure: Current strategies and future perspectives to improve liver hypertrophy before major oncological liver resection Clinical success rates for portal vein embolization are high, exceeding 95 percent in large series regardless of whether segmental or main-trunk embolization is used.10PubMed Central. Future liver remnant hypertrophy and postoperative outcomes: a retrospective comparison between segmental and main right portal vein embolization
Portal vein embolization typically requires four to six weeks before the liver has grown enough to proceed safely. For patients whose tumors may progress during that wait, a more aggressive strategy called ALPPS (associating liver partition and portal vein ligation for staged hepatectomy) can accelerate regrowth dramatically. In a comparison of ALPPS and portal vein embolization for liver cancer patients, ALPPS produced a far greater hypertrophy rate, increasing the remnant volume by nearly 49 percent over about six days.11Annals of Surgery. ALPPS Versus Portal Vein Embolization for Hepatitis-related Hepatocellular Carcinoma ALPPS involves two operations in quick succession: the first splits the liver in half and ties off the portal vein, and the second completes the resection days later once the remnant has grown. The rapid timeline comes at a cost, since ALPPS carries higher complication rates than portal vein embolization and is generally reserved for patients who cannot afford the weeks-long wait.
How the Operation Is Done
Trisegmentectomy is among the most technically complex abdominal operations. The procedure begins with mobilizing the liver, freeing it from the ligaments that attach it to the diaphragm and abdominal wall. The surgeon then identifies and controls the inflow blood vessels (the hepatic artery and portal vein branches) and the outflow vessels (hepatic veins) serving the portions of the liver to be removed. Techniques for vascular control vary, but the standard approach includes managing the hilar structures, gaining control of the hepatic veins outside the liver, and intermittently clamping the entire inflow to the liver when needed during transection, a maneuver known as the Pringle maneuver.12JAMA Surgery. One Hundred Consecutive Hepatic Resections: Blood Loss, Transfusion, and Operative Technique
Dividing the liver tissue itself, called parenchymal transection, is the step that determines much of the blood loss. Surgeons use various devices to crush, dissect, or seal the tissue while preserving the vessels and bile ducts running through it. Ultrasonic dissectors, water-jet tools, and surgical staplers have all been studied, and no single instrument has proven clearly superior to the others for liver transection in general.13PubMed. Comparative analysis of different transection techniques in minor and major hepatic resections In bulky or posteriorly located tumors, an early series showed that identifying and controlling the right hepatic vein from within the liver itself aided safe resection, a technique that remains useful today.14PubMed Central. Right trisegmentectomy for hepatic neoplasms
Keeping Blood Loss Under Control
Blood loss is one of the strongest predictors of complications after major liver surgery, and anesthesiologists play a surprisingly important role in managing it. Keeping the central venous pressure low during parenchymal transection reduces the pressure inside the hepatic veins, which in turn reduces back-bleeding from the cut surface of the liver. One controlled study found that maintaining a low central venous pressure during hepatectomy cut the average blood loss during transection from around 1,660 mL to roughly 670 mL.15PubMed Central. Low central venous pressure reduces blood loss in hepatectomy A randomized trial of laparoscopic liver resections confirmed the effect, finding that intentional low-venous-pressure management nearly halved total blood loss compared with a standard anesthesia approach.16PubMed. Intention to control low central venous pressure reduced blood loss during laparoscopic hepatectomy In practice, anesthesia teams achieve this through careful fluid restriction, patient positioning, and sometimes medications that reduce venous return. Another study found that patients whose central venous pressure stayed at 5 mmHg or less averaged under 500 mL of blood loss, while those above 5 mmHg averaged over 2,000 mL.17PubMed. Low central venous pressure anesthesia in major hepatic resection The approach has no lasting adverse effects on kidney or liver function, which was the original concern when the strategy was first proposed.
Complications Specific to Trisegmentectomy
Post-hepatectomy liver failure is defined as a deterioration of the liver’s ability to maintain its synthetic, excretory, and detoxifying functions, showing up as worsening blood clotting times and rising bilirubin levels on or after the fifth day after surgery.18PubMed Central. Risk factors for post-hepatectomy liver failure in 80 patients The risk climbs steeply with the amount of liver removed, which is why trisegmentectomy carries a higher failure rate than smaller operations. In one early case series, the operative mortality for right trisegmentectomy was about 3 percent, and late liver insufficiency was not seen among survivors.19PubMed Central. Right trisegmentectomy for hepatic neoplasms Modern mortality rates at high-volume centers are in a similar range, though they rise sharply at hospitals that perform fewer of these procedures.
Bile leaks are another frequent complication. When the liver is divided, small bile ducts along the transection surface can ooze bile into the abdomen. Among patients who developed bile leaks in one series, about three-quarters had leaks from the central bile duct system rather than from tiny peripheral ducts. Most were managed without reoperation, though healing often took months; the median time to resolution was 92 days for centrally located leaks treated with biliary drainage.20PubMed Central. Risk Factors and Managements of Bile Leakage After Hepatectomy Peripheral leaks that did not communicate with the main bile duct system were sometimes treated with chemical ablation, sealing off the leaking duct with a sclerosing agent.
Minimally Invasive Trisegmentectomy
Laparoscopic and robotic liver surgery have expanded rapidly over the past two decades, but trisegmentectomy remains one of the hardest operations to perform through small incisions. The scope of the resection, the need for precise vascular control, and the complexity of the transection plane all push up the risk of converting to an open procedure. An analysis of the National Surgical Quality Improvement Program database found that undergoing a trisegmentectomy carried the highest odds of unplanned conversion during robotic liver surgery, with roughly six and a half times the conversion risk compared with simpler robotic liver resections.21HPB. Risk factors and outcomes in patients undergoing minimally invasive hepatectomy with unplanned conversion Unplanned conversion is not a failure in the strictest sense, since the operation still gets done, but it is associated with worse short-term outcomes than either a planned open approach or a successfully completed minimally invasive one. For this reason, many centers still prefer open surgery for trisegmentectomy unless the team has extensive minimally invasive hepatobiliary experience.
When a Smaller Operation Might Work Instead
Trisegmentectomy is not always the only option. For some patients, particularly those with colorectal liver metastases scattered across multiple segments, a parenchymal-sparing approach removes each tumor individually with narrow margins, preserving as much normal liver as possible. A systematic review and meta-analysis comparing parenchymal-sparing hepatectomy to extended resections for colorectal metastases found that overall survival and recurrence-free survival were essentially the same between the two strategies, while the extended resections carried longer operating times, more blood loss, higher transfusion rates, and more postoperative complications.22PubMed Central. Parenchymal‐sparing versus extended hepatectomy for colorectal liver metastases: A systematic review and meta‐analysis
A more recent single-center study confirmed these findings with an interesting nuance: patients who underwent parenchymal-sparing surgery had higher rates of microscopically positive margins (47 percent vs. 30 percent for major resections), yet their local recurrence rates, recurrence-free survival, and overall survival were not significantly worse.23PubMed. Parenchymal-sparing hepatectomy vs single-stage major hepatectomy for bilateral colorectal liver metastases The rate of post-hepatectomy liver insufficiency was dramatically lower in the parenchymal-sparing group: 1 percent versus 13 percent. These data do not mean that trisegmentectomy is obsolete, because some tumors simply cannot be addressed with a smaller resection. But for bilateral colorectal metastases, preserving tissue where safely possible has become the preferred strategy at many centers.
How the Liver Grows Back
The liver’s ability to regenerate is what makes trisegmentectomy survivable at all. After a major resection, the small remaining portion regrows to nearly the original mass within weeks to months. The process is not simple regrowth of the removed segments; rather, the remaining segments enlarge. Regeneration is driven primarily by hemodynamic changes: when most of the liver is gone, the same volume of portal blood flows through a much smaller organ, increasing portal pressure and shear stress on the remaining tissue. That mechanical signal triggers a cascade of molecular events.24PubMed Central. Liver regeneration after partial hepatectomy: Triggers and mechanisms
After minor resections, the liver compensates primarily through cell enlargement (hypertrophy), where existing cells simply grow bigger. After a trisegmentectomy, where the majority of the organ is gone, cell division (hyperplasia) becomes the dominant mode of recovery. The remaining liver cells divide to repopulate the remnant, and the organ’s internal architecture, including its blood-vessel network and bile duct system, remodels itself over months. Researchers have found that structural remodeling continues well after the liver has regained its original mass, meaning the endpoint of regeneration is not simply “same weight as before” but a more complex return to normal architecture.25PubMed Central. Liver regeneration after partial hepatectomy: Triggers and mechanisms
Recovery and Quality of Life
Hospital stays after trisegmentectomy typically run one to two weeks, depending on whether complications arise. The early postoperative period involves close monitoring of liver function tests, coagulation, and bile output from any surgical drains. Quality-of-life scores tend to dip after major liver surgery, as you would expect after a large abdominal operation, but they generally recover to baseline by about nine months.26PubMed. A systematic review and meta-analysis on the quality of life after hepatic resection One single-center study actually found that patients who underwent major hepatectomy reported higher physical quality-of-life scores than those who had minor resections, possibly because the major-resection group had been more debilitated by their disease before surgery and experienced greater relief afterward.27PubMed Central. Quality of life after curative liver resection: a single center analysis Pain and limitations in daily activities were the strongest factors driving down quality of life when it did suffer, and even minor complications had a measurable impact on reported well-being. The takeaway for patients facing this surgery is that the recovery arc is real but finite: most people who come through the perioperative period without serious complications feel like themselves again within a year.
Trisegmentectomy in Children
Children, most often those with hepatoblastoma, sometimes require trisegmentectomy when the tumor involves too much of the liver for a standard lobectomy. The physiology of a child’s liver is somewhat different: it tends to regenerate faster and more completely than an adult’s. In the early series that reported a 3 percent operative mortality for right trisegmentectomy overall, the results in children were roughly twice as good as in adults in terms of tumor-free follow-up.28PubMed Central. Right trisegmentectomy for hepatic neoplasms More recently, an analysis of a national pediatric surgical database found that children undergoing trisectionectomy had about three and a half times the odds of requiring large-volume blood transfusions compared to those having standard hepatic resections, and perioperative transfusion needs and extended ventilation were both more common in the extended-resection group.29PubMed. Hepatic resections for pediatric hepatoblastoma: analysis of 30-day outcomes using the National Surgical Quality Improvement Program-Pediatric database Despite the higher resource demands, pediatric trisegmentectomy remains a viable curative option, particularly because the alternative for children with unresectable hepatoblastoma is liver transplantation, which carries its own lifelong implications.
Why Hospital and Surgeon Volume Matters
Trisegmentectomy is not a procedure where all hospitals produce equivalent results. The operation demands a multidisciplinary team: a hepatobiliary surgeon comfortable with complex vascular reconstructions, an anesthesiologist who knows how to manage low central venous pressure, an interventional radiologist for preoperative portal vein embolization, and a critical-care team experienced in monitoring liver function after massive resection. The difference between a high-volume center and a low-volume one is not abstract. Studies across many types of complex surgery consistently show that operative mortality for procedures like this can be several times higher at institutions that do them infrequently. If you or a family member are facing a trisegmentectomy, seeking out a center that performs a high volume of major hepatectomies is one of the most consequential decisions you can make, likely more impactful than the specific choice of transection instrument or surgical approach.