Incidental Long Makuuchi ligament and its surgical relevance in pediatric hepatic resection

The surgical relevance of Makuuchi ligament (inferior vena cava ligament) has been less explored, especially in pediatric population. With the advent of major hepatectomies and liver transplantation indicated for various malignancies and metabolic conditions in children, knowledge about IVC ligament seems essential, in terms of its draining vessels, contained hepatic tissue and close relation with caudate lobe. Herein, we present a 2 years old female child diagnosed with hepatoblastoma (PRE-Treatment-EXTent of tumor II and POST-Treatment EXTent of tumor II) (PRETEXT II, and POSTTEXT II), with tumor involving right hepatic vein, who underwent right hepatectomy. Intraoperatively, after liver mobilization, we encountered a long IVC ligament, in the form of a broad membranous ligament bridging the left and right sides of caval groove encircling IVC completely. With the help of Cavitron Ultrasonic Aspirator (CUSA) and fine Ligaclips, the IVC ligament was meticulously ligated before tumor handling, preventing any major intraoperative bleeding, bile leak and possible tumor spread. Segments V-VIII were resected out to complete a formal anatomical right hepatectomy. The child was shifted to intensive care unit (ICU) on ventilator for postoperative recovery and care. Postoperatively, we did not encounter any signs of hepatic failure and the subhepatic drain output was persistently minimal without any bleed or bile leak.