The first time I met Professor Takasaki was in 1986, at the CICD meeting in Jerusalem, when he presented his personal technique for liver resection. I was very enthusiastic about the originality and simplicity of his method and suggested that he report his experience. I told him that if he wrote a book, I would write the foreword for it. Here I keep my word.
Professor Takasaki's technique for liver resection derives from an original concept of anatomical division of the liver into three segments based on the distribution of the portal branches. This might seem strange when we have been used to the Couinaud anatomy for the past 20 years. In fact, however, there is a close correlation between the two anatomies if we consider that the right portal branch is short or even nonexistent. We can say that portal blood is distributed to three portions of the liver: the right segment, the middle segment, and the left segment for Takasaki; and the right posterior sector, the right anterior sector, and the left liver for Couinaud.1 Thus the liver is divided into three in both classifications.
The second original contribution by Professor Takasaki is the approach to the portal pedicles inside the liver parenchyma. Initially, I was opening the Glisson capsule to clamp and ligate the vascular elements independently but changed many years ago to the Takasaki technique, which is easier, quicker, and safer. Apart from the Pringle maneuver for the whole liver, this technique is the best way to control a part of the liver for liver resection in a real anatomical manner. The video material that accompanies this volume shows the most common liver resections carried out using this technique and provides the best illustration of its quality.
1 The similarity is even greater if we consider, as I said in 1982 in "Anatomical surgery and surgical anatomy of the liver" (World J Surg 6:3-9), that segments 4 and 3 of Couinaud are indeed artificially separated by the exteriorization of the left portal vein by the round ligament: segments 4 and 3 are one segment and, with segment 2, represent one sector. The left liver is indeed one sector. Therefore, the liver is three segments for Takasaki and three sectors (each divided into two segments) for me.
Professor Takasaki is to be complimented for the pioneering advances he has made in the history of liver surgery.
Henri Bismuth Member of the French Academy of Surgery Honorary Fellow of the American College of Surgeons Honorary Fellow of the American Surgical Association
In the field of liver surgery, metastatic liver tumors and primary liver cancer are the two major diseases to be treated. Among the latter, hepatocellular carcinoma is the most prominent and frequent disease encountered in Asia. Surgical treatment for hepatocellular carcinoma is more challenging than for metastatic tumors because of the underlining fibrosis and cirrhosis due to viral hepatitis. Pursuit of the optimal balance between the radical step of removal of the cancer and preservation of the noncancerous liver parenchyma becomes a matter of significance.
The surgical technique for hepatocellular carcinoma (HCC) is demanding. For example, due to liver cirrhosis, hemostasis after liver transection is much more difficult than that for metastatic tumors. Many new techniques have been developed in Asian countries, where hepatocellular carcinoma is prevalent and many hepatic surgeons have been fighting this dismal disease: Tien-Yu Lin from Taiwan, GB Ong from Hong Kong, M Balasegaram from Malaysia, Ton-That Tung and Trinh Van Minh from Vietnam, Ichio Honjo and others from Japan.
Professor Takasaki was with Tokyo Women's Medical University, School of Medicine, for 36 years. During his long career, he devised many new techniques and methodologies that are now considered essential to liver surgery. Among his major contributions are the remaining liver function test, the portal pedicle dissection method from the hilum, and the "anterior approach" in hemi-liver resection.
The remaining liver function test was developed to predict the postoperative hepatic failure from the retention rate of indocyanine green at 15 minutes (ICG 15') and the remnant liver volume. When the postoperative ICG 15' value exceeds 40%, the patient is likely to suffer from liver dysfunction. The "anterior approach" for extended right hemihepatectomy is a technique in which the liver parenchyma is transected from the anterior surface of segment 4 to the inferior vena cava. The technique can be found first in a figure in T. Starzl's paper, published in 1980 in Surgery, Gynecology & Obstetrics. The title of the paper was, however, "Right Trisegmentectomy for Hepatic Neoplasms," and the details of the technique were not well described. The technique was described in detail as the "anterior approach" for the first time by Edward C.S. Lai from Hong Kong in 1996, in the journal World Journal of Surgery. However, Professor Takasaki introduced a detailed, precise description of the technique at an international meeting held in Padua in 1992, 4 years earlier than the Hong Kong group's report. Unfortunately, his work failed to gain international recognition, because the publication of the technique was limited to a Japanese-language surgical journal at the time. Similarly, Professor Bernard Launois from France is often incorrectly thought to have been the first to introduce the method of portal pedicle dissection from the hepatic hilum in the literature. Professor Launois described it as the "posterior" intrahepatic approach in 1992.1 One must realize, however, that Professor Takasaki had described the innovative and elegant technique in 1986, that is, 6 years earlier, long before the publication by Professor Launois. The portal pedicle dissection from the hepatic hilum, or the "Glis-sonean pedicle transaction method" for hepatic resection, is Professor Taka-saki's invention.
When a small unit of the liver is resected, it should be strictly anatomical in patients with HCC. Identification of the relevant area of the liver is essential for this purpose. We performed dye injection into the portal venous branch while Professor Takasaki dissected and clamped the portal pedicles from the hepatic hilum for this purpose.
I am devoted to Professor Takasaki because he is a true liver surgeon, a man of few words, with a sharp mind and excellent hands. He has fought furiously against a deadly disease, and has never ceased his criticism of others, or of himself, to achieve true improvement in the field. He has performed almost 4000 hepatectomies at Tokyo Women's Medical University, School of Medicine.
This volume contains the essence of his ideas and clinical experiences in liver surgery. Its publication is definitely a milestone, and offers a great wealth of experience to both new and experienced surgeons alike who genuinely wish to become masters of liver surgery. The book is filled with original concepts in liver surgery for hepatocellular carcinoma, concepts that are essential for today's HPB surgeons.
Masatoshi Makuuchi Professor, Surgeon in Chief Hepato Biliary Pancreatic Surgery Division Artificial Organ and Transplantation Division Department of Surgery, Graduate School of Medicine,
University of Tokyo and
Chairman, Department of Surgery University of Tokyo Hospital
1 The importance of Glisson's capsule and its sheaths in the intrahepatic approach to resection of the liver. Surgery, Gynecology & Obstetrics, 1992, 174(1):7-10
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