Left jackknife position: a novel position for laparoscopic hepatectomy

Right Kidney Position for Laparoscopic Liver Resection of Tumors Located in the Posterosuperior Region

BACKGROUND

Laparoscopic liver resection (LLR) for tumors located in posterosuperior (PS) region of the liver (segment 7 or 8) is extremely challenging. Several techniques have been proposed; however, no standard procedure has yet been established. The aim of this study was to present and discuss the usefulness of the right kidney position as a unique idea of surgical position in LLR for tumors located in the PS region.

MATERIALS AND METHODS

For the right kidney position, the patient lay on the operating table in the left lateral decubitus position with the body bent so that the kidney rest (approximately the level of the twelfth rib) was elevated to extend the surgical area. The surgeon was positioned on the right or left side of the patient according to the situation during operation. An intercostal port was not used in any of the cases. The operating table was liberally rotated as per the surgeon's preference. The liver was mobilized by dividing the right triangular and coronary ligaments. Full mobilization of the right liver was not routinely performed. Liver transection was performed under intermittent inflow occlusion in all cases.

RESULTS

Thirteen patients with tumors located in the PS region underwent LLR in the right kidney position at Shinshu University Hospital between June 2019 and May 2021. Of the 13 patients, 11 patients underwent limited liver resection and two underwent anatomic liver resection of segment 8. The right kidney position enables the surgeon to secure a wider surgical field under the dome and prevent the camera and forceps from hitting the ilium and interfering with the operation, and the surgical device can easily reach the lesion under the dome because of the migration to the caudal side of the liver. No patients required blood transfusion or conversion to open liver resection. The median surgical margin was 6 mm (range 0 to 9 mm).

CONCLUSIONS

The right kidney position is useful, especially for the resection of tumors located in the PS region of the liver.

A novel exposure maneuver in laparoscopic right hepatectomy

BACKGROUND AND OBJECTIVES

Laparoscopic access to the posterosuperior and lateral parts of the right liver is difficult for blocked and deep surgical situations. We invented a novel water bag device (WBD) to improve the exposure of the right liver.

METHODS

Eighteen consecutive patients with lesions isolated to the posterosuperior or lateral right liver were included in our research. They underwent laparoscopic right hepatectomy with the help of the device and were compared with previous similar laparoscopic cases of our operating surgeon.

RESULTS

The device was successfully employed without related complications and provided enhanced and stable surgical exposure. All patients were operated on without the need for blood transfusions or laparotomy conversion. The median operation time and estimated blood loss were 227 minutes (range, 114-568) and 88 mL (range, 25-250), respectively. In all cases, tumor-free surgical margins were confirmed and no major complications were observed. The results were better than those in previous similar laparoscopic cases.

CONCLUSIONS

The WBD is safe and effective for laparoscopic exposure when lesions are located in the posterosuperior and lateral parts of the right liver. With the help of the device, laparoscopic right liver resection is easier to perform instead of undergoing open hepatectomy.

Theory of Relativity for Posterosuperior Segments of the Liver

BACKGROUND

The accessibility to posterosuperior segments of the liver has traditionally constituted a restrain to adopt the laparoscopic approach in this setting. To overcome this challenge, multiple approaches have been reported in literature. Total transabdominal approach has been previously described for this purpose, even though the rationale to standardly adopt it and a technical depiction of how to achieve an optimal mobilization has never been specifically addressed.

METHODS

Total transabdominal purely laparoscopic approach to posterosuperior segments of the liver is presented, with detailed emphasis to the rotational motions targeted in laparoscopy. A literature review is presented to summarize all other possible accesses to posterosuperior area of the liver. The institutional series for the laparoscopic approach to Sg 7, Sg 6+7, and Sg8 is retrospectively described.

RESULTS

Three rotational motions of the liver are specifically addressed in a video presentation and described for the laparoscopic total-transabdominal approach; the local institutional series using this approach is presented. Other miscellaneous approaches identified from literature encompassing variations in operative position, transabdominal, transthoracic, and combined approaches are described.

CONCLUSIONS

Complete mobilization of the ligaments of the liver leads to a rotation of the transection line in front of the operator's view, allowing to achieve a safe total trans-abdominal laparoscopic approach to the posterosuperior ligaments of the liver, without compromising the vascular inflow control, the possibility to convert to open approach, nor requiring potentially harmful decubitus.

Laparoscopic liver resection: a review of current indications and surgical techniques

Laparoscopic liver resection (LLR) has been the most impressive development in the field of liver surgery in recent two decades. Technical innovations and experience accumulation have made LLR a safe and effective procedure with faster postoperative recovery. Despite the fast spreading of the procedure, details regarding the indications, oncological outcomes and technical essentials were still disputable. To address these issues, two international consensus conferences were hold to update the knowledge in this field. The statements of the both conferences were not conclusive and more high-quality researches are required. In this article, we reviewed the development and the current state of LLR. Indications, outcomes, surgical techniques and devices used in LLR were also discussed.

Useful maneuvers for precise laparoscopic liver resection

Laparoscopic liver resection has evolved over the past decade and nearly replaced open exploration. This procedure not only provides comparable oncological outcomes, but it also has improved recovery after surgery. Many of the challenges presented by limitations of instruments and techniques have been overcome through adaptations and new developments, and it is possible that the remaining obstacles will be overcome within a few years. Moreover, as surgeons continue to gain experience, their technical knowledge has supported further improvement in minimally invasive approaches. This review examines every important procedures in performing a precise laparoscopic liver resection.