Standardization of surgical procedures for laparoscopic Spiegel lobectomy: A single-institutional experience

Laparoscopic caudate lobe resections: How I do it: tips and pitfalls (with video)

BACKGROUND

The caudate lobe (S1) of the liver, due to its deep central position, presents a formidable challenge for laparoscopic resection. Historical skepticism about laparoscopic approaches has been overshadowed by advancements in technology and technique, with recent studies showing comparable outcomes to open surgery.

METHODS

This paper introduces the "Easy First" technique and the Sextet strategies for laparoscopic hepatic caudate lobectomy. The strategies include meticulous preoperative planning, optimal trocar placement, and team positioning, tailored to the anatomical complexities of the caudate lobe.

RESULTS

With a 0% conversion and mortality rate, our series demonstrates the safety of the "Easy First" technique. The Sextet strategies have been instrumental in navigating the technical challenges, emphasizing the importance of patient selection and surgeon expertise.

CONCLUSION

The "Easy First" technique, with its structured approach and the Sextet strategies, offers a replicable method for laparoscopic caudate lobectomy. It underscores the need for stringent patient selection, advanced technical skill, and high-volume center expertise to ensure procedural success and patient safety.

Procedural outcomes of laparoscopic caudate lobe resection: A systematic review and meta-analysis

A systematic review was conducted in compliance with PRISMA statement standards to identify all studies reporting outcomes of laparoscopic resection of benign or malignant lesions located in caudate lobe of liver. Pooled outcome data were calculated using random-effects models. A total of 196 patients from 12 studies were included. Mean operative time, volume of intraoperative blood loss, and length of hospital stay were 225 minutes (95% confidence interval [CI], 181-269 minutes), 134 mL (95% CI, 85-184 mL), and 7 days (95% CI, 5-9 days), respectively. The pooled risk of need for intraoperative transfusion was 2% (95% CI, 0%-5%). It was 3% (95% CI, 1%-6%) for conversion to open surgery, 6% (95% CI, 0%-19%) for need for intra-abdominal drain, 1% (95% CI, 0%-3%) for postoperative mortality, 2% (95% CI, 0%-4%) for biliary leakage, 2% (95% CI, 0%-4%) for intra-abdominal abscess, 1% (95% CI, 0%-4%) for biliary stenosis, 1% (95% CI, 0%-3%) for postoperative bleeding, 1% (95% CI, 0%-4%) for pancreatic fistula, 2% (95% CI, 1%-5%) for pulmonary complications, 1% (95% CI, 0%-4%) for paralytic ileus, and 1% (95% CI, 0%-4%) for need for reoperation. Although the available evidence is limited, the findings of the current study might be utilized for hypothesis synthesis in future studies. They can be used to inform surgeons and patients about estimated risks of perioperative complications until a higher level of evidence is available.

Laparoscopic Medial-to-Lateral Approach for the Resection of Hepatocellular Carcinoma Located at the Spiegel Lobe of the Liver

BACKGROUND

Laparoscopic caudate lobe resection is a challenging procedure. Several researchers have reported the safety of laparoscopic liver resections;1.Transl Gastroenterol Hepatol. 1:56;2.Asian J Endosc Surg. 12:232-236;3.Ann Surg Oncol. 26:2980; however, a standardized procedure has not yet been established. Herein, we present a video showing laparoscopic Spiegel lobectomy in a patient with 6-cm hepatocellular carcinoma (HCC) using a novel approach.

PATIENT AND METHODS

A 63-year-old man with a caudate lobe HCC was referred to our hospital. Computed tomography showed a 5 × 6 cm² HCC located in the Spiegel lobe, which profoundly displaced the inferior vena cava (IVC) to the lower right side, and mobilization of the Spiegel lobe was considered difficult. To perform the dissection between the Siegel lobe and IVC safely, we performed parenchymal transection along the ventral side of the IVC initially. The Spiegel lobe was then dislocated to the left side of the IVC. We dissected the left lateral side of the IVC, including the proper hepatic vein draining the caudate lobe and the left IVC ligament with a safe operative field, and successfully removed the Spiegel lobe with large HCC.

RESULTS

The operation time was 383 min. The blood loss was 10 mL. The patient was discharged on the seventh postoperative day without any complications. Histopathological examination revealed well-differentiated HCC with a negative surgical margin.

CONCLUSIONS

Laparoscopic medial-to-lateral approach with initial parenchymal transection at the medial side of the Spiegel lobe followed by dissection of the left lateral side of the IVC is considered as a safe and effective procedure for large tumors in the Spiegel lobe.

Laparoscopic Caudate Hepatectomy for a Recurrent Tumor Behind the Vena Cava After Multiple Open Hepatectomies (With Video)

BACKGROUND

Caudate hepatectomy is one of the most difficult procedures among liver surgeries because of its deep location and proximity to the inferior vena cava (IVC), particularly in patients with a history of open hepatectomies. 1,2,3 METHODS: A 77-year-old man underwent three open hepatectomies for hepatocellular carcinoma (HCC), including a sub-segmentectomy of S6 and partial hepatectomies of S7 and S8 during follow-up for hepatitis C virus-associated liver cirrhosis. However, HCC recurred in the caudate lobe behind the IVC (Supplemental video file 1). We lysed the severe adhesion in the upper abdomen, including the liver hilum, and exposed the ventral surface of the caudate lobe. We then used a Nathanson retractor to ventrally retract the severely enlarged left lobe. To counteract the severe adhesion that prevented us from controlling the hepatoduodenal ligament, we used the laparoscopic Satinsky vascular clamp for hilar inflow control. Using the anterior approach, we performed parenchymal resection from the distal side of the caudate lobe. Then, we gradually exposed the ventral surface of the IVC and separated the caudate lobe from the IVC. The IVC ligament was divided, and the caudate lobe, including the tumor behind the IVC, was removed.

RESULTS

The operation time was 229 min with a total hepatic hilar clamping time of 69 min and blood loss of 10 mL. The patient was discharged on postoperative day 8 without any complications. Pathological examination revealed moderately differentiated HCC (pT1N0M0) with a negative surgical margin.

CONCLUSIONS

The laparoscopic approach using specialized laparoscopic instruments is feasible for a tumor located in the caudate lobe behind the IVC, even in patients with a history of multiple open hepatectomies.