Open liver resection

• Supine position, arms abducted or tucked depending on access and monitoring.
• A slight reverse Trendelenburg (head-up) tilt is commonly used for upper abdominal exposure.
• Some surgeons use mild Trendelenburg during parenchymal transection to help maintain very low central venous pressure and reduce hepatic-vein bleeding.
• The operating table should allow rotation and lateral tilt to improve exposure of the hepatic dome and posterior segments.

Laparoscopic liver resection

• Usually French position: patient supine with legs apart, surgeon standing between the legs.
• Reverse Trendelenburg, approximately 15-30 degrees, helps the bowel fall caudally and improves access to the liver.
• For right-sided lesions, use a left tilt or elevate the right side as needed.
• For posterior-superior lesions, especially segments VII, VIII, and sometimes VI, use a modified left lateral decubitus / left semilateral position, with the right side elevated. This exposes the posterior right lobe and improves instrument alignment.

Key precautions

• Secure the patient carefully to prevent sliding in reverse Trendelenburg.
• Pad pressure points and protect arms from brachial plexus injury.
• Reverse Trendelenburg and pneumoperitoneum can reduce venous return, so coordinate positioning with anesthesia, particularly in patients with poor cardiac reserve.
• Maintain low CVP during transection when appropriate, but avoid hypovolemia and impaired organ perfusion.