Laparoscopic liver resection of segment 8 via a hepatic parenchymal transection-first approach guided by the middle hepatic vein

Intrahepatic Glisson Intrathecal Dissection via a Hepatic Parenchymal Transection-First Approach for Laparoscopic Anatomical Hemihepatectomy in Patients with Left/Right Glisson Pedicle Involvement

Background: Because of lack of an appropriate surgical approach, laparoscopic surgery in patients with left/right Glisson pedicle involvement is still rarely conducted. This study aimed to discusses the methods of intrahepatic Glisson intrathecal dissection via a hepatic parenchymal transection-first approach for laparoscopic hemihepatectomy in patients with left/right Glisson pedicle involvement. Materials and Methods: We retrospectively analyzed the clinical data of 21 patients who underwent laparoscopic hepatectomy in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from March 2021 to May 2022. Results: The mean age of the patients was 53.1 ± 11.6 years; mean operation time, 191.9 ± 22.3 minutes; median intraoperative blood loss, 205 mL (160-300 mL); and median length of hospital stay, 8 days (7-9 days). None of the patients underwent conversion to open procedure. Thirteen patients had pathologically confirmed hepatocellular carcinoma (HCC) with portal tumor thrombi (PVTT), and 8 was confirmed hepatolithiasis. Intraoperative frozen pathology and final pathology showed tumor free surgical margins in HCC with PVTT patients. After conservative treatment, all the complications such as postoperative liver section effusion, pleural effusion, pneumonia, intra-abdomen bleeding, and bile leak were cured. During outpatient follow-up examination, no other abnormality was detected. All HCC with PVTT patients were treated with a tyrosine kinase inhibitor after the operation and survived tumor-free. Conclusions: Proposed here is a more safe and feasible method of laparoscopic hemihepatectomy in patients with left/right Glisson pedicle involvement, but many problems still needs further exploration.

A safe and simple exposure and Pringle maneuver in laparoscopic anatomical liver resection of segment 7

BACKGROUND

Laparoscopic access to liver segment 7 (S7) is difficult for deep surgical situations and bleeding control. Herein, our proposed laparoscopic technique for S7 lesions using a self-designed tube method is introduced.

METHODS

Clinical data of patients who underwent laparoscopic anatomical liver resection of S7 (LALR-S7) with the help of our self-designed tube to improve the exposure of S7 and bleeding control in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from April 2019 to December 2021 were retrospectively analyzed to evaluate feasibility and safety.

RESULTS

Nineteen patients were retrospectively reviewed. The mean age was 51.3 ± 10.3 years; mean operation time, 194.5 ± 22.7 min; median blood loss, 160.0 ml (150.0-205.0 ml); and median length of hospital stay, 8.0 days (7.0-9.0 days). There was no case conversion to open surgery. Postoperative pathology revealed all cases of hepatocellular carcinoma (HCC). Free surgical margins were achieved in all patients. No major postoperative complications were observed. Patients with postoperative complications recovered after conservative treatment. During outpatient follow-up examination, no other abnormality was presented. All patients survived without tumor recurrence.

CONCLUSIONS

The preliminary clinical effect of our method was safe, reproducible and effective for LALR-S7. Further research is needed due to some limitations of this study.

Augmented Reality Navigation Plus Indocyanine Green Fluorescence Imaging Can Accurately Guide Laparoscopic Anatomical Segment 8 Resection

BACKGROUND

Laparoscopic anatomical Segment 8 (S8) resection is a highly challenging hepatectomy. Augmented reality navigation (ARN), which could be combined with indocyanine green (ICG) fluorescence imaging, has been applied in various complex liver resections and may also be applied in laparoscopic anatomical S8 resection. However, no study has explored how to apply ARN plus ICG fluorescence imaging (ARN-FI) in laparoscopic anatomical S8 resection, or explored its accuracy.

PATIENTS AND METHODS

This study is a post hoc analysis that included 31 patients undergoing laparoscopic anatomical S8 resection from the clinical NaLLRFI trial, and the resected liver volume was measured in each patient. The perioperative parameters of safety and feasibility, as well as the accuracy analysis outcomes were compared.

RESULTS

There were 16 patients in the ARN-FI group and 15 patients underwent conventional laparoscopic hepatectomy without ARN or fluorescence imaging (non-ARN-FI group). There was no significant difference in baseline characteristics between the two groups. Compared with the non-ARN-FI group, the ARN-FI group had lower intraoperative bleeding (median 125 vs. 300 mL, P = 0.003). No significant difference was observed in other postoperative short-term outcomes. Accuracy analysis indicated that the actual resected liver volume (ARLV) in the ARN-FI group was more accurate.

CONCLUSIONS

ARN-FI was associated with less intraoperative bleeding and more accurate resection volume. These techniques may address existing challenges and provide rational guidance for laparoscopic anatomical S8 resection.

Approaches of laparoscopic anatomical liver resection of segment 8 for hepatocellular carcinoma: a retrospective cohort study of short-term results at multiple centers in China

BACKGROUND

Laparoscopic anatomical liver resection of segment 8 (LALR-S8) remains a challenge for anatomical laparoscopic segmentectomy. Most current reports on LALR-S8 are case series using one surgical approach, and there is a lack of multicenter data on identifying intersegmental planes using different approaches. In this study, the authors aimed to elucidate the short-term results of three different approaches for LALR-S8 for hepatocellular carcinoma (HCC), focusing on intersegmental plane determination, and to reflect on current practice regarding different approaches at multiple centers in China.

MATERIALS AND METHODS

The clinical cohort data of 122 patients who underwent LALR-S8 for HCC at seven leading centers in China were retrospectively analyzed. The surgical procedures of all approaches were summarized and standardized according to the method of the Glissonean pedicle of segment 8 identification. The postoperative short-term outcomes and oncological results of the three approaches were evaluated and compared.

RESULTS

Three approaches were used: laparoscopic ultrasonography-guided indocyanine green fluorescent positive staining approach (11/122, 9.02%), hepatic vein-guided approach (99/122, 81.15%), and Glissonean indocyanine green fluorescent negative staining approach (12/122, 9.83%). Seven (5.73%) patients experienced complications according to the Clavien-Dindo classification, and the rate of grade ≥IIIa complications was 2.46%. The R0 resection rates among the groups (margin >1 mm) and the margin width showed no statistical difference.

CONCLUSION

LALR-S8 is safe and feasible for treating HCC under standardized surgical techniques and appropriate surgical approaches. The three reported approaches had comparable short-term oncological outcomes, while the hepatic vein-guided approach was most commonly used.