Lateral approach liver hanging maneuver in laparoscopic anatomical liver resections

Minimally Invasive Left Hepatectomy: Choosing the Suitable Surgical Strategy

BACKGROUND

Numerous surgical techniques are currently available for minimally invasive left hepatic resection, each offering its own advantages and disadvantages.

PATIENTS AND METHODS

This multimedia manuscript delves into the primary approaches for minimally invasive left hepatectomy, with a focus on particular topics such as left hepatic vein approach, transection and middle hepatic vein exposure, and Glissonean approach. We examine key factors that surgeons should consider when choosing among these methods and provide practical recommendations.

RESULTS

To enhance understanding, our article includes video footage from multiple centres, showcasing expertly executed surgeries for each approach along with their main considerations.

CONCLUSIONS

This multimedia resource will serve as a valuable guide for surgeons, aiding in the selection of the most suitable strategy for minimally invasive left hepatectomies, tailored to the specific needs of the patient and the characteristics of the lesion.

Pure Laparoscopic Hepatectomy for Tumors Close to the Major Hepatic Veins: Intraparenchymal Identification of the Major Hepatic Veins using the Ventral Approach

BACKGROUND

Laparoscopic hepatectomy for tumors close to the major hepatic veins (HVs) is a technically demanding procedure that is relatively contraindicated. We investigated this surgical technique and the outcomes of intraparenchymal identification of the major HVs using the ventral approach in pure laparoscopic hepatectomy for tumors close to the major HVs.

METHODS

In the present study, tumors < 10 mm from the major HVs were defined as lesions in proximity to the major HVs. The cranio-ventral part of the liver parenchyma along the targeted major hepatic veins was opened to facilitate an open cutting plane. After a wide exposure of the surgical plane, the targeted major HVs were identified.

RESULTS

Thirteen patients with tumors close to the major HVs underwent laparoscopic hepatectomy. The median operative time was 260 min (range, 160-410 min), while the intraoperative blood loss was 100 mL (range, 30-310 mL). The median Pringle maneuver time was 45 min (range, 40-75 min). The median tumor size was 50 mm (range, 17-140 mm), and the median tumor margin was 4 mm (range, 0-10 mm). Three patients (23.1%) experienced minor postoperative complications. The median postoperative hospital stay was 7 days (range, 4-25 days).

CONCLUSIONS

Pure laparoscopic hepatectomy for tumors close to the major HVs is technically feasible in selected patients. Intraparenchymal identification of the major HVs using the ventral approach achieves transection plane accuracy and avoids inadvertent injury to the major HVs.

Landmarks and techniques to perform minimally invasive liver surgery: A systematic review with a focus on hepatic outflow

PURPOSE

In this systematic review, we aimed to clarify the useful anatomic structures and assess available surgical techniques and strategies required to safely perform minimally invasive anatomic liver resection (MIALR), with a particular focus on the hepatic veins (HVs).

METHODS

A systematic review was conducted using MEDLINE/PubMed for English articles and Ichushi databases for Japanese articles through September 2020. The quality assessment of the articles was performed in accordance with the Scottish Intercollegiate Guidelines Network (SIGN).

RESULTS

A total of 3372 studies were obtained, and 59 were selected and reviewed. Due to the limited number of published comparative studies and case series, the degree of evidence from our review was low. Thirty-two articles examined the anatomic landmarks and crucial structures for approaching HVs. Regarding the direction of HV exposure, 32 articles focused on the techniques and advantages of exposing HVs from either the root or the periphery. Ten articles focused on the techniques to perform a segmentectomy 8 in particularly difficult cases of MIALR. In seven articles, bleeding control from HVs was also discussed.

CONCLUSIONS

This review may help experts reach a consensus regarding the best approach to the management of hepatic veins during MIALR.

Modified liver hanging maneuver in laparoscopic major hepatectomy: the learning curve and evolution of indications

BACKGROUND

Laparoscopic major hepatectomy is a technically challenging procedure requiring a steep learning curve. The liver hanging maneuver is a useful technique in liver resection, especially for large or invasive tumors, a relative contraindication of the laparoscopic approach. Therefore, this study aimed to evaluate the learning curve for laparoscopic major hepatectomy using the liver hanging maneuver and extended indications.

METHODS

Patients who underwent laparoscopic major hepatectomy using the liver hanging maneuver by a single surgeon from January 2013 and September 2018 were retrospectively reviewed. Our hanging technique involves placing the hanging tape along the inferior vena cava for right-sided hepatectomy or the ligamentum venosum for left-sided hepatectomy. The upper end of the tape was placed at the lateral side of the major hepatic veins. The learning curve for operating time and blood loss was evaluated using the cumulative sum (CUSUM) method.

RESULTS

Among 53 patients, 18 underwent right hepatectomy, 26 underwent left hepatectomy, and 9 underwent right posterior sectionectomy. CUSUM analysis showed that operative time and blood loss improved after the 30th laparoscopic major hepatectomy. The 53 consecutive patients were divided into two groups (early, patients 1-30; late, patients 31-53). The median operative time was lower in the late group, but the difference was not statistically significant (270 vs. 245 min, p = 0.261). The median blood loss was also significantly lower in the late group (350 vs. 150 ml, p < 0.001). Large tumors (measuring > 10 cm) and tumors in proximity to major vessels were significantly higher in the late group (0 vs. 17.4%, p = 0.018; 3.3 vs. 21.7%, p = 0.036; respectively).

CONCLUSION

This study shows that laparoscopic major hepatectomy using the modified liver hanging maneuver has a learning curve of 30 cases. After procedure standardization, the indications have gradually been extended to large or invasive tumors.

Pure Laparoscopic Right Posterior Sectionectomy Using the Glissonean Approach and a Modified Liver Hanging Maneuver (Video)

BACKGROUND

Laparoscopic right posterior sectionectomy is technically challenging secondary to poor exposure of the surgical field and difficulty with controlling hemorrhage during deeper parenchymal transection Cho et al., Surgery 158:135-141, 2015; Lee et al., Surgery 160:1219-1226, 2016. We present laparoscopic right posterior sectionectomy using the Glissonean approach and a modified liver hanging maneuver.

METHODS

A 57-year-old man presented with a single mass in segment 7 of the liver. He was placed in the lithotomy position, and five trocars were used in the upper abdomen. The hepatoduodenal ligament was encircled using an umbilical tape to perform the intermittent Pringle maneuver. After detachment of the hilar plate, the right posterior Glissonean pedicle was dissected and clamped to confirm ischemic delineation Takasaki, J Hepato-Biliary-Pancreat Surg 5:286-291, 1998. After complete mobilization of the right liver, the hanging tape was placed along the inferior vena cava between the caval ligament and the right hepatic vein. The hanging tape elevates the liver and guides the surgeon to achieve an accurate transection plane Belghiti et al., J Am Coll Surg 193:109-111, 2001; Kim et al., Surg Endosc 30:3611-3617, 2016; Kim, Choi, J Gastrointest Surg 21:1181-1185, 2017; Kim et al., Langenbecks Arch Surg 403:131-135, 2018 . The transection plane used during a right posterior sectionectomy is horizontal and follows the inferior vena cava. However, with the liver hanging maneuver, the horizontal transection plane becomes vertical.

RESULT

The operation time was 290 min, the estimated blood loss was 120 mL, and the total Pringle maneuver time was 60 min. Final histopathological diagnosis showed a 1.7-cm-sized hepatocellular carcinoma with the resection margin measuring 1.5 cm. The patient was discharged on postoperative day 7 without any complications.

CONCLUSION

A Glissonean approach with a modified liver hanging maneuver is feasible and useful for laparoscopic right posterior sectionectomy.

Laparoscopic Right Hepatectomy Via an Anterior Approach for Hepatocellular Carcinoma

Background and Objectives

In the past, right hepatectomy via the anterior approach has been regarded as one of the many standard approaches for hepatectomy. However, total laparoscopic right hepatectomy from the anterior approach has been regarded as technically challenging. We report our experience in using the anterior approach in total laparoscopic right hepatectomy for hepatocellular carcinoma (HCC).

Methods

From June 2013 through December 2015, five consecutive patients underwent total laparoscopic right hepatectomy using the anterior approach, but without the hanging maneuver.

Results

The mean operative time was 360 (range, 300-480) minutes, and the mean blood loss was 340 (110-600) mL. No patient needed any blood transfusion. There was no conversion to open surgery. Ascites, pleural effusion, and bile leakage occurred in 2, 1, and 1 patients, respectively. No patients expired as a result of the surgery or liver failure. The mean hospital stay was 7 (4-15) days. All patients had R0 resection. After a mean follow-up of 22 (8-33) months, no patients experienced recurrence of disease.

Conclusion

Total laparoscopic right hepatectomy using the anterior approach is feasible and safe.

Usefulness of the Ligamentum Venosum as an Anatomical Landmark for Safe Laparoscopic Left Hepatectomy (How I Do It)

Anatomical landmarks are commonly utilized in surgical practice to help surgeons to maintain an anatomical orientation. The ligamentum venosum (LV) is an anatomical landmark that is utilized during left hepatectomy via both the open and the laparoscopic approaches. We describe the usefulness of the LV as an anatomical landmark in performing a safe laparoscopic left hepatectomy. The key characteristic of our technique is that the LV is divided at the end of the surgery. Our technique involves identification and dissection of the LV, but we do not divide it during liver mobilization. The LV marks the boundary for safe vascular inflow control of the left hemiliver. Following exposure of the middle hepatic vein, hepatic parenchymal transection is curved toward the LV, which serves as a landmark to guide surgeons to achieve an optimal plane of transection in the late stages. A suitable transection point of the left bile duct is determined based on the location of the LV. Between February 2013 and September 2017, 21 consecutive patients underwent pure laparoscopic left hepatectomy. The median operation time was 240 min (range 180-350 min), and the median intraoperative estimated blood loss was 200 ml (range 80-600 ml). Major postoperative complications occurred in one patient (4.8%). The median postoperative hospital stay was 8 days (range 5-15 days). This systematic approach using the LV as an anatomical landmark may serve as a safe and effective technique to perform a laparoscopic left hepatectomy.

Pure Laparoscopic Right Hepatectomy Using Modified Liver Hanging Maneuver: Technical Evolution from Caudal Approach Toward Ventral Approach

BACKGROUND

The liver hanging maneuver during right hepatectomy is a useful technique for parenchymal transection. The laparoscopic caudal approach is totally different from the laparoscopic ventral approach because of the direction of parenchymal transection. There are differences in the application and effectiveness of liver hanging maneuver between two approaches. This study evaluated the surgical techniques and outcomes of the ventral approach comparison with the caudal approach in laparoscopic right hemihepatectomy using liver hanging maneuver.

METHODS

From February 2013 to February 2018, 16 patients underwent laparoscopic right hepatectomy using liver hanging maneuver. The caudal approach was used in 10 patients and the ventral approach in six. We adopted a different avascular plane located between the right adrenal gland and the vena cava for the hanging tape placement. In the caudal approach, the liver parenchyma were transected from the caudal to cranial side, pulling the hanging tape caudally. In the ventral approach, the parenchyma were transected from the ventral to the dorsal side, pulling the hanging tape superiorly.

RESULTS

The clinical data and patient characteristics of both groups were similar. The median operation time was comparable between the two groups (275 vs. 278 min, p = 0.958). The median blood loss was significantly lower using the ventral approach group than the caudal approach group (375 vs. 190 ml, p = 0.016). The difference in median postoperative hospital stay was not statistically significant (9 vs. 8 days, p = 0.713).

CONCLUSION

This ventral approach with liver hanging maneuver is a feasible and useful technique for laparoscopic right hemihepatectomy.

Minimally invasive donor hepatectomy, are we ready for prime time?

Minimally invasive surgery potentially reduces operative morbidities. However, pure laparoscopic approaches to donor hepatectomy have been limited by technical complexity and concerns over donor safety. Reduced-wound donor hepatectomy, either in the form of a laparoscopic-assisted technique or by utilizing a mini-laparotomy wound, i.e., hybrid approach, has been developed to bridge the transition to pure laparoscopic donor hepatectomy, offering some advantages of minimally invasive surgery. To date, pure laparoscopic donor left lateral sectionectomy has been validated for its safety and advantages and has become the standard in experienced centres. Pure laparoscopic approaches to major left and right liver donation have been reported for their technical feasibility in expert hands. Robotic-assisted donor hepatectomy also appears to be a valuable alternative to pure laparoscopic donor hepatectomy, providing additional ergonomic advantages to the surgeon. Existing reports derive from centres with tremendous experience in both laparoscopic hepatectomy and donor hepatectomy. The complexity of these procedures means an arduous transition from technical feasibility to reproducibility. Donor safety is paramount in living donor liver transplantation. Careful donor selection and adopting standardized techniques allow experienced transplant surgeons to safely accumulate experience and acquire proficiency. An international prospective registry will advance the understanding for the role and safety of pure laparoscopic donor hepatectomy.

A systematic surgical procedure: The '7+3' approach to laparoscopic right partial hepatectomy [deep segment (S) VI, S VII or S VIII] in 52 patients with liver tumors

Laparoscopic right partial hepatectomy (LRPH), located in the deep segment (S) VI, S VII or S VIII, is a complicated procedure, due to its poor operative field and high risk of bleeding. The present study aimed to summarize our experience of LRPH and to share our systematic surgical procedure, the ‘7+3’ approach. This approach includes seven key points and three main instruments. A total of 81 cases were included, which were divided into 2 groups [LRPH, n=52; open hepatectomy (OH), n=29]. The demographic profile, intraoperative parameters and postoperative parameters were obtained and analyzed. Blood loss (245.38±268.37 ml) in the LRPH group was not significantly more than in the OH group (230.93±257.62 ml; P=0.936). The durations of surgery, liver parenchyma transection and portal triad clamping were also not significantly more than those in the OH group (145.52±48.29 vs. 129.83±35.04 min; P=0.149 for surgery; 28.52±10.16 vs. 23.97±10.44 min; P=0.059 for liver parenchyma transection; 20.62±9.61 vs. 17.31±10.12 min; P=0.149 for portal triad clamping). However, the number of postoperative hospital days in the LRPH group was smaller (10.67 in LRPH vs. 12.07 in OH; P=0.025). The present study demonstrated the satisfactory surgical outcomes and economic benefits of the systematic ‘7+3’ surgical technique for LRPH. Further studies in larger cohorts and other centers are required to confirm its feasibility and superiority.

Highlights of the Third Expert Forum of Asia-Pacific Laparoscopic Hepatectomy; Endoscopic and Laparoscopic Surgeons of Asia (ELSA) Visionary Summit 2017

The application of laparoscopy for liver surgery is rapidly increasing and the past few years have demonstrated a shift in paradigm with a trend towards more extended and complex resections. The development of instruments and technical refinements with the effective use of magnified caudal laparoscopic views have contributed to the ability to overcome the limitation of laparoscopic liver resection. The Endoscopic and Laparoscopic Surgeons of Asia (ELSA) Visionary Summit 2017 and the 3^rd Expert Forum of Asia-Pacific Laparoscopic Hepatectomy organized hepatobiliary pancreatic sessions in order to exchange surgical tips and tricks and discuss the current status and future perspectives of laparoscopic hepatectomy. This report summarizes the oral presentations given at the 3^rd Expert Forum of Asia-Pacific Laparoscopic Hepatectomy.

Laparoscopic liver hanging maneuver through the retrohepatic tunnel on the right side of the inferior vena cava combined with a simple vascular occlusion technique for laparoscopic right hemihepatectomy

Background

Laparoscopic hepatectomy has been performed in many hospitals, with the development of the laparoscopic operation technique. However, performing complex laparoscopic hepatectomy, such as right hemihepatectomy, is still a challenge. The aim of this study was to describe the application of a simple vascular occlusion technique and new liver hanging maneuver (LHM) in complex laparoscopic hepatectomy, which are both advocated by Chen Xiaoping for open hepatectomy.

Methods

The clinical data of 29 consecutive patients who underwent laparoscopic right hemihepatectomy (LRH) from October 2014 to October 2016 were retrospectively analyzed. During operation, the vascular occlusion technique without hilus dissection and LHM through the retrohepatic avascular tunnel on the right side of the inferior vena cava were used.

Result

All 29 operations were successfully performed laparoscopically, while adopting Chen’s methods. The study consisted of 23 patients with hepatocellular carcinoma, four patients with intrahepatic cholangiocarcinoma, and two patients with hepatic metastasis of colonic carcinoma. The tumor size was 12.4 ± 1.9 cm. The operation time of LRH was 190.3 ± 49.9 min. The intraoperative blood loss of LRH was 281.7 ± 117.8 mL; five patients required blood transfusion, and the amount of blood transfusion was 300.0 ± 89.4 mL. No case was converted to open surgery, and no death occurred. All resulted in R0 resections. The median free margin was 20.1 ± 10.8 mm. The time of postoperative oral diet intake was 2.10 ± 0.96 days. The complication rate was 17.2%. The average hospital stay after operation was 10.0 ± 2.9 days.

Conclusion

Complex hepatectomy is a bloodless procedure that can be performed under a laparoscope safely using Chen’s methods of vascular occlusion technique and LHM.

Modified liver hanging maneuver focusing on outflow control in pure laparoscopic left-sided hepatectomy

BACKGROUND

Outflow control during laparoscopic liver resection necessitates the use of technically demanding procedures since the hepatic veins are fragile and vulnerable to damage during parenchymal transection. The liver hanging maneuver reduces venous backflow bleeding during deep parenchymal transection. The present report describes surgical outcomes and a technique to achieve outflow control during application of the modified liver hanging maneuver in patients undergoing laparoscopic left-sided hepatectomy.

METHODS

A retrospective review was performed of clinical data from 29 patients who underwent laparoscopic left-sided hepatectomy using the modified liver hanging maneuver between February 2013 and March 2017. For this hanging technique, the upper end of the hanging tape was placed on the lateral aspect of the left hepatic vein. The tape was then aligned with the ligamentum venosum. The position of the lower end of the hanging tape was determined according to left-sided hepatectomy type. The hanging tape gradually encircled either the left hepatic vein or the common trunk of the left hepatic vein and middle hepatic vein.

RESULTS

The surgical procedures comprised: left lateral sectionectomy (n = 10); left hepatectomy (n = 17); and extended left hepatectomy including the middle hepatic vein (n = 2). Median operative time was 210 min (range 90-350 min). Median intraoperative blood loss was 200 ml (range 60-600 ml). Two intraoperative major hepatic vein injuries occurred during left hepatectomy. Neither patient developed massive bleeding or air embolism. Postoperative major complications occurred in one patient (3.4%). Median postoperative hospital stay was 7 days (range 4-15 days). No postoperative mortality occurred.

CONCLUSIONS

The present modified liver hanging maneuver is a safe and effective method of outflow control during laparoscopic left-sided hepatectomy.

A Modified Liver Hanging Maneuver in Pure Laparoscopic Left Hemihepatectomy with Preservation of the Middle Hepatic Vein: Video and Technique

BACKGROUND

The liver hanging maneuver is a novel and useful technique that is widely used in open liver resections. The present study describes the surgical technique and outcomes of a modified liver hanging maneuver for pure laparoscopic left hemihepatectomy.

METHOD

The clinical data of patients who underwent laparoscopic left hemihepatectomy using a modified hanging technique were retrospectively reviewed. The upper end of the hanging tape was placed on the lateral side of the left hepatic vein. The pathway of the tape was situated along the ligamentum venosum.

RESULTS

Sixteen patients underwent pure laparoscopic left hemihepatectomy with the modified hanging technique. The median operation time was 225 min (range 180-300 min), with a median blood loss of 265 ml (range 140-600 ml). Postoperative major complications occurred in one patient (6.3%). The median postoperative hospital stay was 8 days (range 5-15 days). There was no postoperative liver failure or mortality.

CONCLUSION

This modified liver hanging maneuver is a simple, safe, and reproducible approach as dissection of between the middle and left hepatic vein is not required. This technique may be useful in laparoscopic left hemihepatectomy.

The liver hanging maneuver in laparoscopic liver resection: a systematic review

PURPOSE

Laparoscopic surgery has gained the acceptance of the hepatobiliary surgical community and expert teams are now advocating major laparoscopic liver resections (LLRs). In this setting, the liver hanging maneuver (LHM) has been described in numerous series. We conducted a systematic review to investigate the effectiveness of the LHM in LLR.

METHODS

We performed an electronic literature search using PubMed, EMBASE, and COCHRANE databases. The final search was carried out in December, 2015.

RESULTS

We found 11 articles describing a collective total of 104 surgical procedures that were eligible for this study. Laparoscopic LHM was used in LLR for both benign and malignant conditions, and also in living donor liver transplantation (LDLT). The LHM was used mainly in right hepatectomy and only two authors reproduced the original LHM. We investigated the intraoperative parameters, preservation of postoperative liver function, and oncological outcomes. The clear benefit of using the LHM in LLR is for better identification of the parenchymal transection plane with less blood loss. The other benefits of LHM could not be corroborated by solid data on its positive value.

CONCLUSIONS

In view of the data published in the literature, our findings are not strong enough to support the systematic use of LHM in LLR.

Can retrohepatic tunnel be quickly and easily established for laparoscopic liver hanging maneuver by Goldfinger dissector in laparoscopic right hepatectomy?

OBJECTIVE

The liver hanging maneuver (LHM) is rarely applied in laparoscopic right hepatectomy (LRH) because of the difficulty encountered in retrohepatic tunnel (RT) dissection and tape positioning. Thus far no report has detailed how to quickly and easily establish RT for laparoscopic LHM in LRH, nor has employment of the Goldfinger dissector to create a total RT been reported. This study's aim was to evaluate the safety and feasibility of establishing RT for laparoscopic LHM using the Goldfinger dissector in LRH.

METHODS

Between March 2015 and July 2015, five consecutive patients underwent LRH via the caudal approach with laparoscopic LHM. A five-step strategy using the Goldfinger dissector to establish RT for laparoscopic LHM was adopted. Perioperative data were analyzed.

RESULTS

The median age of patients was 58 (range, 51-65) years. Surgery was performed for one intrahepatic lithiasis and four hepatocellular carcinomas with a median size of 90 (40-150) mm. The median operative time was 320 (282-358) min with a median blood loss of 200 (200-600) ml. Laparoscopic LHM was achieved in a median of 31 (21-62) min, and the median postoperative hospital stay was 14 (9-16) d. No transfusion or conversion was required, and no severe liver-related morbidity or death was observed.

CONCLUSIONS

The Goldfinger dissector is a useful instrument for the establishment of RT. A five-step strategy using the Goldfinger dissector can quickly and easily facilitate an RT for a laparoscopic LHM in LRH.