Feasible laparoscopic repeat hepatectomy using double intercostal ports and laparoscopic vascular clamp (with video)

BackgroundLaparoscopic repeat hepatectomy is a technically challenging procedure owing to adhesions around the liver, causing difficulties in performing hepatic inflow control by conventional tourniquet method [1], and failure in hepatic mobilization [2].MethodThus, we introduce our technique using double intercostal ports to manipulate the fixed liver under the rib cage and using the laparoscopic Satinsky vascular clamp to perform hepatic inflow control to overcome the aforementioned concerns in ipsilateral laparoscopic repeat hepatectomy after previous open hepatectomy.VideoThe patient, with histories of abdominal aortic aneurysm repair and open Segment 7 subsegmentectomy, had recurrent hepatocellular carcinoma in the dorsal region of Segment 8. After establishing pneumoperitoneum with five abdominal ports, adhesiolysis around the liver was then performed, followed by identification of the caudal part of Spiegel's lobe as the landmark for the space between the left-side of the hepatoduodenal ligament and the vena cava. Although the space between the right side of the hepatoduodenal ligament and the vena cava was obstructed, the laparoscopic blunt-tip Satinsky vascular clamp successfully was applied on the stiff hepatoduodenal ligament due to previous hepatectomy and made inflow control. Because the liver could not be mobilized at all, double intercostal ports with balloons were introduced [3] for parenchymal resection for exposing the parenchymal resection plane and also to apply the vessel sealing device. A 12-Fr chest tube (Aspiration Kit. Argyle™, Tokyo, Japan) was introduced in the right thoracic cavity as our routine.ResultsThe operative time was 243 minutes and the blood loss was 50g. The postoperative course was uneventful and the patient was discharged on the day 8.ConclusionsThe combination of intercostal ports and laparoscopic Satinsky vascular clamp could be significant aids for performing safe ipsilateral laparoscopic repeat hepatectomy, even after previous open hepatectomy.     

Digital intelligent technology assisted three-dimensional laparoscopic extended left hepatectomy with resection of the middle hepatic vein(Video)

IntroductionDigital intelligent technology represented by three-dimensional (3D) visualization technology and surgical navigation system may provide preoperative and intraoperative anatomical information more accurately than CT and MRI [1]. Besides, the fusion of 3D model with surgical visual field through surgical navigation system may also compensate for the defects of visual fields and tactile sense to some extent in laparoscopic liver surgery [2].VideoA 49-year-old male patient with a tumor mainly located at the left inner area of liver and oppressing the middle hepatic vein (MHV). We formulated preoperative planning by using the Medical Image 3D Visualization System (MI3DVS, software copyright No: 2008SR18798) [3]. It was acknowledged that the right hepatic vein (RHV) was strong enough to drain the right anterior hepatic sector. Ultimately, 3D laparoscopic extended left hepatectomy with resection of the MHV was selected as the optimal operation scheme for the patient due to the RHV would avoid hepatic venous congestion in segment V and VIII after resection of the MHV, and more liver parenchyma than left trisegmentectomy would be retained. The operation was performed under assistance of the Laparoscopic Hepatectomy Navigation System (LHNS, software copyright No. 2018SR840555) [4].ResultsThe total operation time was 180 min, estimated blood loss of 200 ml. The final histopathological diagnosis showed an 8*6*6-cm-sized hepatocellular carcinoma. And the patient was discharged on postoperative day 6 without any complications.ConclusionDigital intelligent technology may be helpful to formulate preoperative planning and identify intraoperative important anatomical structures in 3D laparoscopic extended left hepatectomy with resection of the MHV.     

Robotic central hepatectomy for hepatocarcinoma by glissonean approach (with video)

BackgroundCentral bisegmentectomy of the liver implies excising Couinaud's segments IV, V and VIII (Couinaud and Le Foie, 1957) [1]. In a recent classification of laparoscopic liver resections, it belongs to the highly advanced level procedure group (Kawaguchi and et al., 2018 Jan) [2]. Improvement in laparoscopic devices should lead to a wider accessibility of such indications that are currently expert prerogatives. In order to illustrate the assets of robotic-assistance in the management of highly difficult mini-invasive hepatic resections, we present the case of a robotic central hepatectomy.MethodsThis video illustrates robotic central hepatectomy in a 70-year-old male. A liver tumor involving segments IV, V and VIII was incidentally detected during abdominal ultrasonography. CT scan and MRI suggested the diagnosis of a seventy-millimeter centrally located hepatocellular carcinoma and surgical resection was decided.ResultsThe patient was placed supine in anti-Trendelenburg position. Four robotic trocars were placed and the da Vinci X robotic system was docked. Two laparoscopic ports were placed for the second surgeon (ultrasonic dissector and suction/irrigation set). Central hepatectomy was performed with a glissonean approach. Robotic irrigated bipolar coagulation and laparoscopic ultrasonic dissector was used for parenchymal transection. Postoperative course was uneventful. The patient was discharged on postoperative day eight.ConclusionThe recent publication of an International consensus statement demonstrates the growing involvement of robotics in liver surgery (Liu and et al., 2019 March 28) [3]. Robotic advantages (flexibility, absence of fulcrum effect and visual field stability) could improve accessibility to minimal invasive approach for difficult liver resection.     

Impact of body mass index on the difficulty and outcomes of laparoscopic left lateral sectionectomy

IntroductionCurrently, the impact of body mass index (BMI) on the outcomes of laparoscopic liver resections (LLR) is poorly defined. This study attempts to evaluate the impact of BMI on the peri-operative outcomes following laparoscopic left lateral sectionectomy (L-LLS).MethodsA retrospective analysis of 2183 patients who underwent pure L-LLS at 59 international centers between 2004 and 2021 was performed. Associations between BMI and selected peri-operative outcomes were analyzed using restricted cubic splines.ResultsA BMI of >27kg/m2 was associated with increased in blood loss (Mean difference (MD) 21 mls, 95% CI 5–36), open conversions (Relative risk (RR) 1.13, 95% CI 1.03–1.25), operative time (MD 11 min, 95% CI 6–16), use of Pringles maneuver (RR 1.15, 95% CI 1.06–1.26) and reductions in length of stay (MD -0.2 days, 95% CI -0.3 to −0.1). The magnitude of these differences increased with each unit increase in BMI. However, there was a “U” shaped association between BMI and morbidity with the highest complication rates observed in underweight and obese patients.ConclusionIncreasing BMI resulted in increasing difficulty of L-LLS. Consideration should be given to its incorporation in future difficulty scoring systems in laparoscopic liver resections.     

Laparoscopic left ventral hepatic segmentectomy (with video)

BackgroundThe anatomical resection of Segment 3 and 4 of the liver under conventional laparotomy was reported [1]. We present the laparoscopic approach for this type of resection.MethodLaparoscopic left ventral hepatic segmentectomy [2] including the Segment 3 (S3) and the ventral Segment 4 (S4v), preserving the Segment 2 (S2) and the dorsal Segment 4 (S4d), was performed for the hepatocellular carcinoma located at the root of the Glissonean pedicle of the S3.VideoAfter the pneumoperitoneum and the mobilization of the left lateral segment, the Glissonean pedicle for the left ventral segment was controlled and occluded. The demarcation line between the left ventral segment and the Segment 2 (S2), the dorsal Segment 4 (S4d) and the Segment 5 (S5) was confirmed using indocyanine green-fluorescence imaging [3]. The hepatic parenchymal resection was started along the demarcation line between the S3 and S2 on the dorsal lateral segment [4], followed by the division of the Glissonean pedicle of the left ventral segment. Further parenchymal division between the S4v and S4d, and that between the S4v and S5 resulted in the completion of the laparoscopic left ventral hepatic segmentectomy.ResultsThe operative time was 221 minutes and the intraoperative blood loss was 10 ml. The postoperative course was uneventful and the patient was discharged 7days after the surgery.ConclusionsThe left ventral hepatic segmentectomy could be among the standard choices of laparoscopic anatomical resection for a tumor located around the top of the umbilical portion in selected HBP institutes.     

Laparoscopic-specific procedure using dorsal approach to the middle hepatic vein in laparoscopic left hemihepatectomy

BackgroundExposing the middle hepatic vein (MHV) is required in left hemihepatectomy [1]. Laparoscopy enables us to perform unique approach in performing hepatectomy [2,3]. Herein we show a video of dorsal approach in left hemihepatectomy and measure anatomical parameters useful for approaching to the MHV.PatientA 79-year-old man with colorectal liver metastasis underwent laparoscopic left hemihepatectomy.TechniqueAfter mobilizing left lateral section and encircling left Glissonian trunk, we firstly flipped up left lateral section inside and began parenchymal transection from dorsal surface around the root of left hepatic vein (LHV). Immediately we touched the MHV and, by cutting the left Glissonian trunk, could extend complete MHV exposure in central-to-peripheral direction without split injuries of MHV branches [2]. Next, we flipped down the left lateral section and divided ventral remaining parenchyma in caudal-to-cranial direction without risk of MHV injury. As this is not one-way procedure [4], as if open a book, we adjusted the ventral cutting plane to match with the dorsal one. Finally, by cutting the LHV, we completed left hemihepatectomy.Measuring anatomical parametersWe divided a sectional image into four zones (cranio-dorsal, caudal-dorsal, caudal-ventral, and cranio-ventral zones) and measured each anatomical parameter to expose the MHV. The area of cranio-dorsal zone was smallest to expose the MHV (3.5cm²). The distance from the Arantius’ ligament to the MHV was also shortest (1.1cm).ConclusionsDorsal approach might be the nearest and safe road way to the MHV. This approach might make it easy to complete laparoscopic left hemihepatectomy.     

Cranial approach to the left hepatic vein in laparoscopic anatomic liver resections of segment 2 and segment 3

BackgroundThe cranial approach allows easy identification of the major hepatic vein Ome et al. (2020), Honda et al. (2013), Xiao et al. (2016) and Kim (2019) [[1], [2], [3], [4]] and avoids split injury of the hepatic veins (HV) by exposing the HV from the root to the periphery (Honda et al., 2013) [2]. We present the cranial approach to laparoscopic anatomic liver resections of segment 2 (S2) and segment 3 (S3) in two cases of hepatocellular carcinoma (HCC).Methods[Laparoscopic segmentectomy 2]After dissection of the S2 Glissonean pedicle, parenchymal transection was initiated to expose the dorsal aspect of the root of the left hepatic vein via parenchymal transection using a cranial approach. The cavitron ultrasonic surgical aspirator (CUSA) was used from the root side towards the peripheral side. The liver parenchymal dissection was completed by dissecting between the demarcation line and the left hepatic vein. [Laparoscopic segmentectomy 3]The liver transection was initiated along the falciform ligament. After the S3 Glissonean pedicle was temporally clamped, the ventral aspect of the root of the left hepatic vein was exposed peripherally. The parenchymal dissection process was completed with the S3 Glissonean pedicle dissection.ResultsS2: The operation time was 191 min, the estimated blood loss was 5 ml, and the patient was discharged on postoperative day 5 with no complications. S3: The total operation time was 215 min, the estimated blood loss was 50 ml, and the patient was discharged on postoperative day 9 with no complications.ConclusionThe cranial approach is a safe method for laparoscopic anatomic liver resections of segments 2 and 3.     

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

BackgroundLaparoscopic 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.PatientA 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).MethodAfter 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.ResultsThe 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.ConclusionLaparoscopy-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 distal pancreatectomy with regional lymphadenectomy through retroperitoneal-first laparoscopic approach (Retlap) for locally advanced pancreatic body cancer

BackgroundLaparoscopic distal pancreatectomy (LDP) is widely performed [1,2]. However, LDP with regional lymphadenectomy for locally advanced pancreatic cancer (LAPC) is technically demanding [3]. We previously reported a new strategy named “retroperitoneal-first laparoscopic approach (Retlap)” for distal pancreatectomy with en bloc celiac axis resection [4]. In this study, Retlap is applied during LDP with regional lymphadenectomy (see Fig. 1).MethodsThis video demonstrates the case of a 70-year-old woman with a 100 × 40-mm LAPC. Preoperative computed tomography revealed a large tumor near the root of the celiac axis and acute pancreatitis in the pancreatic head. An ample dorsal margin should be secured and regional lymphadenectomy performed because of the large tumor. In Retlap, the celiac axis was exposed using the retroperitoneal approach from the dorsal side of the pancreatic body, and then the left adrenal grand and left celiac ganglion were removed. Without interfering with the tumor, the root of the splenic artery was identified, facilitating easy performance of lymphadenectomy around the celiac axis and superior mesenteric artery in Retlap. After dividing the splenic artery, the procedure was converted to laparoscopic approach and resection was completed.ResultsThe operative time and estimated blood loss were 487 min and 45 mL, respectively. Pathological examination confirmed a negative surgical margin, and R0 resection was achieved with uneventful postoperative course.ConclusionRetlap was technically feasible and useful for achieving adequate and secure surgical margin and regional lymphadenectomy. Retlap can help secure the operative field of view in difficult cases of LAPC.     

Comparison of transanal total mesorectal excision (TaTME) versus laparoscopic TME for rectal cancer: A case matched study

BackgroundTransanal total mesorectal excision (TaTME) has been developed to improve the quality of laparoscopic TME for patients with rectal cancer. Recently, international concern on TaTME was raised by a national cohort study showing an increased rate of local recurrences. This study aimed to compare clinicopathological and mid-term oncological outcomes of TaTME versus laparoscopic TME (LaTME) for mid and low rectal cancer of a high volume center.MethodsFrom August 2014 to October 2019, patients with mid or low rectal cancer who received TaTME procedure were identified. The cases were matched with patients treated with LaTME. Data were retrospectively collected including operative details, postoperative morbidity, pathologic results, and oncologic outcomes. Primary endpoint was the local recurrence (LR) rate.ResultsPropensity score matching yielded 70 patients in each of the groups. There were no statistically significant differences between the 2 groups in terms of postoperative complications, conversion rate to open surgery and circumferential resection margin. Local recurrence occurred in 2 patients (2.9%) in the transanal group, whereas 1 patient developed a local recurrence in the laparoscopic group (1.4%)(p = 0.559). Kaplan–Meier survival analysis showed a 2 year Local recurrence rate 1.5% VS 1.6%(p = 0.934), DFS 88.0% VS 87.7%, OS 94.0% vs 100% for transanal and laparoscopic group, respectively.ConclusionsIn a high volume center the transanal total mesorectal procedure is feasible, and appears to be safe alternative to laparoscopic surgery. Oncological outcomes were acceptable and no increased multi or unifocal local recurrence rate was found.     

Retroperitoneal-first laparoscopic approach (Retlap)-assisted distal pancreatectomy with celiac axis resection (DP-CAR): A novel minimally invasive approach for achieving adequate dorsal surgical margin

BackgroundDistal pancreatectomy with celiac axis resection (DP-CAR) is a procedure to secure a surgical margin for a locally advanced pancreatic body cancer that invades the celiac axis. However, in patients with cancer close to the root of the celiac axis, obtaining adequate surgical margins can be difficult because the tumor obstructs the field of vision to the root of the celiac axis. Previously, we described the retroperitoneal-first laparoscopic approach (Retlap) to achieve both accurate evaluation of resectability for locally advanced pancreatic cancer requiring DP-CAR [1] and adequate surgical margin for laparoscopic distal pancreatectomy [2]. In this video, we introduce Retlap-assisted DP-CAR as a minimally invasive approach for performing an artery-first pancreatectomy [3, 4] and achieving sufficient dorsal surgical margin (Fig. 1).MethodsOur patient is a 67-year-old man with a 55 × 29-mm pancreatic body tumor after chemotherapy. Preoperative computed tomography revealed a tumor close to the root of the celiac axis. Because the area of tumor invasion on preoperative images was near the root of the celiac artery, Retlap-assisted DP-CAR was performed to determine whether the celiac axis can be secured and obtain an adequate dorsal surgical margin (Fig. 2).ResultsThe operative time and estimated blood loss was 715 min and 449 mL, respectively. In spite of the advanced tumor's location and size, R0 resection was achieved in a minimally invasive way.ConclusionRetlap-assisted DP-CAR is not only technically feasible and useful for achieving accurate evaluation of resectability but also facilitates obtaining an adequate surgical margin.