A Modified Liver Hanging Maneuver in Pure Laparoscopic Left Hemihepatectomy with Preservation of the Middle Hepatic Vein: Video and Technique

Minimally Invasive Left Hepatectomy: Choosing the Suitable Surgical Strategy

BACKGROUND

Numerous surgical techniques are currently available for minimally invasive left hepatic resection, each offering its own advantages and disadvantages.

PATIENTS AND METHODS

This multimedia manuscript delves into the primary approaches for minimally invasive left hepatectomy, with a focus on particular topics such as left hepatic vein approach, transection and middle hepatic vein exposure, and Glissonean approach. We examine key factors that surgeons should consider when choosing among these methods and provide practical recommendations.

RESULTS

To enhance understanding, our article includes video footage from multiple centres, showcasing expertly executed surgeries for each approach along with their main considerations.

CONCLUSIONS

This multimedia resource will serve as a valuable guide for surgeons, aiding in the selection of the most suitable strategy for minimally invasive left hepatectomies, tailored to the specific needs of the patient and the characteristics of the lesion.

Modified liver hanging maneuver in laparoscopic major hepatectomy: the learning curve and evolution of indications

BACKGROUND

Laparoscopic major hepatectomy is a technically challenging procedure requiring a steep learning curve. The liver hanging maneuver is a useful technique in liver resection, especially for large or invasive tumors, a relative contraindication of the laparoscopic approach. Therefore, this study aimed to evaluate the learning curve for laparoscopic major hepatectomy using the liver hanging maneuver and extended indications.

METHODS

Patients who underwent laparoscopic major hepatectomy using the liver hanging maneuver by a single surgeon from January 2013 and September 2018 were retrospectively reviewed. Our hanging technique involves placing the hanging tape along the inferior vena cava for right-sided hepatectomy or the ligamentum venosum for left-sided hepatectomy. The upper end of the tape was placed at the lateral side of the major hepatic veins. The learning curve for operating time and blood loss was evaluated using the cumulative sum (CUSUM) method.

RESULTS

Among 53 patients, 18 underwent right hepatectomy, 26 underwent left hepatectomy, and 9 underwent right posterior sectionectomy. CUSUM analysis showed that operative time and blood loss improved after the 30th laparoscopic major hepatectomy. The 53 consecutive patients were divided into two groups (early, patients 1-30; late, patients 31-53). The median operative time was lower in the late group, but the difference was not statistically significant (270 vs. 245 min, p = 0.261). The median blood loss was also significantly lower in the late group (350 vs. 150 ml, p < 0.001). Large tumors (measuring > 10 cm) and tumors in proximity to major vessels were significantly higher in the late group (0 vs. 17.4%, p = 0.018; 3.3 vs. 21.7%, p = 0.036; respectively).

CONCLUSION

This study shows that laparoscopic major hepatectomy using the modified liver hanging maneuver has a learning curve of 30 cases. After procedure standardization, the indications have gradually been extended to large or invasive tumors.

Pure Laparoscopic Right Posterior Sectionectomy Using the Glissonean Approach and a Modified Liver Hanging Maneuver (Video)

BACKGROUND

Laparoscopic right posterior sectionectomy is technically challenging secondary to poor exposure of the surgical field and difficulty with controlling hemorrhage during deeper parenchymal transection Cho et al., Surgery 158:135-141, 2015; Lee et al., Surgery 160:1219-1226, 2016. We present laparoscopic right posterior sectionectomy using the Glissonean approach and a modified liver hanging maneuver.

METHODS

A 57-year-old man presented with a single mass in segment 7 of the liver. He was placed in the lithotomy position, and five trocars were used in the upper abdomen. The hepatoduodenal ligament was encircled using an umbilical tape to perform the intermittent Pringle maneuver. After detachment of the hilar plate, the right posterior Glissonean pedicle was dissected and clamped to confirm ischemic delineation Takasaki, J Hepato-Biliary-Pancreat Surg 5:286-291, 1998. After complete mobilization of the right liver, the hanging tape was placed along the inferior vena cava between the caval ligament and the right hepatic vein. The hanging tape elevates the liver and guides the surgeon to achieve an accurate transection plane Belghiti et al., J Am Coll Surg 193:109-111, 2001; Kim et al., Surg Endosc 30:3611-3617, 2016; Kim, Choi, J Gastrointest Surg 21:1181-1185, 2017; Kim et al., Langenbecks Arch Surg 403:131-135, 2018 . The transection plane used during a right posterior sectionectomy is horizontal and follows the inferior vena cava. However, with the liver hanging maneuver, the horizontal transection plane becomes vertical.

RESULT

The operation time was 290 min, the estimated blood loss was 120 mL, and the total Pringle maneuver time was 60 min. Final histopathological diagnosis showed a 1.7-cm-sized hepatocellular carcinoma with the resection margin measuring 1.5 cm. The patient was discharged on postoperative day 7 without any complications.

CONCLUSION

A Glissonean approach with a modified liver hanging maneuver is feasible and useful for laparoscopic right posterior sectionectomy.

Usefulness of the Ligamentum Venosum as an Anatomical Landmark for Safe Laparoscopic Left Hepatectomy (How I Do It)

Anatomical landmarks are commonly utilized in surgical practice to help surgeons to maintain an anatomical orientation. The ligamentum venosum (LV) is an anatomical landmark that is utilized during left hepatectomy via both the open and the laparoscopic approaches. We describe the usefulness of the LV as an anatomical landmark in performing a safe laparoscopic left hepatectomy. The key characteristic of our technique is that the LV is divided at the end of the surgery. Our technique involves identification and dissection of the LV, but we do not divide it during liver mobilization. The LV marks the boundary for safe vascular inflow control of the left hemiliver. Following exposure of the middle hepatic vein, hepatic parenchymal transection is curved toward the LV, which serves as a landmark to guide surgeons to achieve an optimal plane of transection in the late stages. A suitable transection point of the left bile duct is determined based on the location of the LV. Between February 2013 and September 2017, 21 consecutive patients underwent pure laparoscopic left hepatectomy. The median operation time was 240 min (range 180-350 min), and the median intraoperative estimated blood loss was 200 ml (range 80-600 ml). Major postoperative complications occurred in one patient (4.8%). The median postoperative hospital stay was 8 days (range 5-15 days). This systematic approach using the LV as an anatomical landmark may serve as a safe and effective technique to perform a laparoscopic left hepatectomy.

Pure Laparoscopic Right Hepatectomy Using Modified Liver Hanging Maneuver: Technical Evolution from Caudal Approach Toward Ventral Approach

BACKGROUND

The liver hanging maneuver during right hepatectomy is a useful technique for parenchymal transection. The laparoscopic caudal approach is totally different from the laparoscopic ventral approach because of the direction of parenchymal transection. There are differences in the application and effectiveness of liver hanging maneuver between two approaches. This study evaluated the surgical techniques and outcomes of the ventral approach comparison with the caudal approach in laparoscopic right hemihepatectomy using liver hanging maneuver.

METHODS

From February 2013 to February 2018, 16 patients underwent laparoscopic right hepatectomy using liver hanging maneuver. The caudal approach was used in 10 patients and the ventral approach in six. We adopted a different avascular plane located between the right adrenal gland and the vena cava for the hanging tape placement. In the caudal approach, the liver parenchyma were transected from the caudal to cranial side, pulling the hanging tape caudally. In the ventral approach, the parenchyma were transected from the ventral to the dorsal side, pulling the hanging tape superiorly.

RESULTS

The clinical data and patient characteristics of both groups were similar. The median operation time was comparable between the two groups (275 vs. 278 min, p = 0.958). The median blood loss was significantly lower using the ventral approach group than the caudal approach group (375 vs. 190 ml, p = 0.016). The difference in median postoperative hospital stay was not statistically significant (9 vs. 8 days, p = 0.713).

CONCLUSION

This ventral approach with liver hanging maneuver is a feasible and useful technique for laparoscopic right hemihepatectomy.

Highlights of the Third Expert Forum of Asia-Pacific Laparoscopic Hepatectomy; Endoscopic and Laparoscopic Surgeons of Asia (ELSA) Visionary Summit 2017

The application of laparoscopy for liver surgery is rapidly increasing and the past few years have demonstrated a shift in paradigm with a trend towards more extended and complex resections. The development of instruments and technical refinements with the effective use of magnified caudal laparoscopic views have contributed to the ability to overcome the limitation of laparoscopic liver resection. The Endoscopic and Laparoscopic Surgeons of Asia (ELSA) Visionary Summit 2017 and the 3^rd Expert Forum of Asia-Pacific Laparoscopic Hepatectomy organized hepatobiliary pancreatic sessions in order to exchange surgical tips and tricks and discuss the current status and future perspectives of laparoscopic hepatectomy. This report summarizes the oral presentations given at the 3^rd Expert Forum of Asia-Pacific Laparoscopic Hepatectomy.

Modified liver hanging maneuver focusing on outflow control in pure laparoscopic left-sided hepatectomy

BACKGROUND

Outflow control during laparoscopic liver resection necessitates the use of technically demanding procedures since the hepatic veins are fragile and vulnerable to damage during parenchymal transection. The liver hanging maneuver reduces venous backflow bleeding during deep parenchymal transection. The present report describes surgical outcomes and a technique to achieve outflow control during application of the modified liver hanging maneuver in patients undergoing laparoscopic left-sided hepatectomy.

METHODS

A retrospective review was performed of clinical data from 29 patients who underwent laparoscopic left-sided hepatectomy using the modified liver hanging maneuver between February 2013 and March 2017. For this hanging technique, the upper end of the hanging tape was placed on the lateral aspect of the left hepatic vein. The tape was then aligned with the ligamentum venosum. The position of the lower end of the hanging tape was determined according to left-sided hepatectomy type. The hanging tape gradually encircled either the left hepatic vein or the common trunk of the left hepatic vein and middle hepatic vein.

RESULTS

The surgical procedures comprised: left lateral sectionectomy (n = 10); left hepatectomy (n = 17); and extended left hepatectomy including the middle hepatic vein (n = 2). Median operative time was 210 min (range 90-350 min). Median intraoperative blood loss was 200 ml (range 60-600 ml). Two intraoperative major hepatic vein injuries occurred during left hepatectomy. Neither patient developed massive bleeding or air embolism. Postoperative major complications occurred in one patient (3.4%). Median postoperative hospital stay was 7 days (range 4-15 days). No postoperative mortality occurred.

CONCLUSIONS

The present modified liver hanging maneuver is a safe and effective method of outflow control during laparoscopic left-sided hepatectomy.