Standardization of laparoscopic anatomic liver resection of segment 2 by the Glissonean approach

BACKGROUND

Anatomic liver resection (ALR) has been established to eliminate the tumor-bearing hepatic region with preservation of the remnant liver volume for liver malignancies. Recently, laparoscopic ALR has been widely applied; however, there are few reports on laparoscopic segmentectomy 2. This study aimed to present the standardization of laparoscopic segmentectomy 2 with surgical outcomes.

METHODS

This study included seven patients who underwent pure laparoscopic segmentectomy 2 by the Glissonean approach from January 2020 to December 2021. Four of them had hepatocellular carcinoma, two had colorectal liver metastasis, and one had hepatic angiomyolipoma, which was preoperatively diagnosed with hepatocellular carcinoma. In all patients, preoperative three-dimensional (3D) simulation images from dynamic CT were reconstructed using a 3D workstation. The layer between the hepatic parenchyma and the Glissonean pedicle of segment 2 (G2) was dissected to encircle the root of G2. After clamping or ligation of the G2, 2.5 mg of indocyanine green was injected intravenously to identify the boundaries between segments 2 and 3 with a negative staining method under near-infrared light. Parenchymal transection was performed from the caudal side to the cranial side according to the demarcation on the liver surface, and the left hepatic vein was exposed on the cut surface if possible.

RESULTS

The mean operative time for all patients was 281 min. The mean blood loss was 37 mL, and no transfusion was necessary. Estimated liver resection volumes significantly correlated with actual liver resection volumes (r = 0.61, P = 0.035). After the operation, one patient presented with asymptomatic deep venous and pulmonary thrombosis, which was treated with anticoagulant therapy. The mean length of hospital stay was 8.9 days.

CONCLUSION

Laparoscopic segmentectomy 2 by the Glissonean approach is a feasible and safe procedure with the preservation of the nontumor-bearing segment 3 for liver tumors in segment 2.

Cranio-caudal approach to hepatic veins in laparoscopic central bisectionectomy (with Video)

BACKGROUND

Laparoscopic central bisectionectomy (Couinaud's segment IV, V, and VIII) needs exposure of the RHV and MHV on the surface of the remnant and the resecting side, respectively. Avoiding venous injury is mandatory and laparoscopy-specific cranio-caudal approach to hepatic veins might be helpful [1]. We present this procedure in performing laparoscopic central bisectionectomy.

PATIENT

A 45-year-old female was admitted to our hospital with a 6 cm HCC in the segment VIII and IV. Her comorbid disease was non-cirrhotic HBV hepatitis (Child-Pugh grade A) and diabetes (untreated).

METHOD

After cholecystectomy, G₄ branches were dissected and cut by extra- or intra-hepatic approach. Hilar plate was dissected and the G_ant was encircled and occluded by a vascular clip. Afterwards, exposure of the MHV was started at its root on IVC [2,3] and extended in cranio-caudal direction [1]. After sufficient space was obtained around the G_ant, the G_ant and the MHV were cut. Parenchymal transection between right anterior and right posterior sections was also started form the root of the RHV to its cranio-caudal direction. Liver resection was finished with full exposure of the RHV.

RESULTS

The operating time was 380 minutes, and the blood loss volume was 30 ml. Postoperative CT image showed exposure of the RHV and umbilical portion of Glissonean branch, and no fluid retention.

CONCLUSION

Laparoscopy-specific cranio-caudal approach to hepatic veins may be useful to avoid split injury of venous branches [4], especially if the hepatectomy requires complete exposure of hepatic vein, such as central bisectionectomy.

Laparoscopic anatomic liver resection of segment 7 using a caudo-dorsal approach to the right hepatic vein

BACKGROUND

Laparoscopic anatomic liver resection of segment 7 (S7) is technically challenging because of the posterosuperior location and the lack of clear anatomical landmarks [1-4]. Here, we introduce a caudo-dorsal approach, which may offer a benefit for the difficult procedure.

METHODS

The patient was a 53-year-old man with hepatocellular carcinoma located in S7 of the liver. After the transection of caudate process, the Glissonean pedicle of S7 (G7) extending from the right posterior Glissonean pedicle was identified on the liver dorsal side. The demarcation line was noted by isolating and clamping G7. The intraoperative ultrasound was then used to assess the extent of the tumor. The right hepatic vein was approached from the dorsal side and continuously exposed in a caudal-cranial direction along the anterior surface of inferior vena cava after isolating and cutting the venous branches draining S7. Following the dissection of G7, the liver parenchymal transection was proceeded along the ischemic line between segment 6 and 7 with the ventral cutting plane extended to join the dorsal one. The liver parenchyma of the ventral side of the exposed right hepatic vein (RHV) was further transected from the dorsal side toward the root side of RHV. The resection of S7 was completed with perihepatic ligaments dissection.

RESULTS

The intermittent Pringle maneuver (15 min occlusion and 5 min reperfusion) was applied when necessary with a total time of 45 min. The operation time was 200 min, the estimated blood loss was 300 ml, and no transfusion was required. Pathology confirmed moderately differentiated HCC with negative surgical margin. The patient was discharged on postoperative day 8 with no complications and has been followed up for 8 months without recurrence.

CONCLUSION

This caudo-dorsal approach for laparoscopic anatomical S7 segmentectomy is easy and feasible when performed by experienced surgeons at experienced centers in well-selected patients.

Open Liver Resection, Laparoscopic Liver Resection, and Percutaneous Thermal Ablation for Patients with Solitary Small Hepatocellular Carcinoma (≤30 mm): Review of the Literature and Proposal for a Therapeutic Strategy

BACKGROUND

Patients with a single hepatocellular carcinoma (HCC) ≤3 cm and preserved liver function have the highest likelihood to be cured if treated. The most adequate treatment methods are yet a matter that is debated.

METHODS

We reviewed the literature about open anatomic resection (AR), laparoscopic liver resection (LLR), and percutaneous thermal ablation (PTA).

RESULTS

PTA is effective as resection for HCC < 2 cm, when they are neither subcapsular nor perivascular. PTA in HCC of 2-3 cm is under evaluation. AR with the removal of the tumor-bearing portal territory is recommended for HCC > 2 cm, except for subcapsular ones. In comparison with open surgery, LRR has better short-term outcomes and non-inferior long-term outcomes. LLR is standardized for superficial limited resections and for left-sided AR.

CONCLUSIONS

According to the available evidences, the following therapeutic proposal can be advanced. Laparoscopic limited resection is the standard for any subcapsular HCC. PTA is the first-line treatment for deep-located HCC < 2 cm, except for those in contact with Glissonean pedicles. Laparoscopic AR is the standard for deep-located HCC of 2-3 cm of the left liver, while open AR is the standard for deep-located HCC of 2-3 cm in the right liver. HCC in contact with Glissonean pedicles should be scheduled for resection (open or laparoscopic) independent of their size. Liver transplantation is reserved to otherwise untreatable patients or as a salvage procedure at recurrence.

Anatomic isolated caudate lobectomy: Is it possible to establish a standard surgical flow?

AIM

To establish the surgical flow for anatomic isolated caudate lobe resection.

METHODS

The study was approved by the ethics committee of the Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU). From April 2004 to July 2014, 20 patients were enrolled who underwent anatomic isolated caudate lobectomy at SAHZU. Clinical and postoperative pathological data were analyzed.

RESULTS

Of the total 20 cases, 4 received isolated complete caudate lobectomy (20%) and 16 received isolated partial caudate lobectomy (80%). There were 4 cases with the left approach (4/20, 20%), 6 cases with the right approach (6/20, 30%), 7 cases with the bilateral combined approach (7/20, 35%), 3 cases with the anterior approach (3/20, 15%), and the hanging maneuver was also combined in 2 cases. The median tumor size was 5.5 cm (2-12 cm). The median intra-operative blood loss was 600 mL (200-5700 mL). The median intra-operative blood transfusion volume was 250 mL (0-2400 mL). The median operation time was 255 min (110-510 min). The median post-operative hospital stay was 14 d (7-30 d). The 1- and 3-year survival rates for malignant tumor were 88.9% and 49.4%, respectively.

CONCLUSION

Caudate lobectomy was a challenging procedure. It was demonstrated that anatomic isolated caudate lobectomy can be done safely and effectively.

An optimized procedure for stained bloodless anatomic hepatectomy in canines

BACKGROUND

Poloxamer 407 (P407) is a thermosensitive polymer that can gelatinize at body temperature and dissolve below critical temperature. The aim of this study was to evaluate an optimized procedure for hepatectomy, in which the target liver section was stained with methylene blue, and the blood inflow was occluded with P407.

METHODS

Twelve dogs were randomized into two equal groups. The conventional group (CG) underwent unstained liver resection with the hemi-Pringle maneuver for blood control. After angiography, the optimized group (OG) was cannulated to the target lobar hepatic artery via the femoral artery and to the target segmental portal vein via a branch of the splenic vein. The artery was then occluded with P407, whereas the vein was administered methylene blue and P407 sequentially before excision along the stained border. Blood specimens and necropsy were acquired periodically.

RESULTS

The stained resection margins were clearly visualized and were accompanied by negligible blood loss. The occlusion duration was significantly reduced from 24.5 ± 2.3 min in the conventional group to 18.5 ± 4.9 min in the OG (P < 0.05). The aspartate aminotransferase and alanine aminotransferase levels were less elevated in the OG postoperatively. No significant evidence of pathology was detected in either group.

CONCLUSIONS

This optimized procedure represents an easy, time-saving and effective approach for stained anatomic hepatectomy with temporary intravascular blood occlusion.