Selective Control of the Left Hepatic Vein During Laparoscopic Liver Resection: Arentius' Ligament Approach

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.

Extrahepatic approach for taping the common trunk of the middle and left hepatic veins or the left hepatic vein alone in laparoscopic hepatectomy (with videos)

BACKGROUND

Outflow control is difficult, and techniques required for effectively handling intraoperative hemorrhage during laparoscopic hepatectomy have not previously been adequately reported.

METHODS

Sixteen patients underwent surgery, of which 15 underwent laparoscopic left hepatectomy and one underwent laparoscopic partial hepatectomy of the caudate lobe. Encircling and taping of the common trunk of the middle (MHV) and left hepatic veins (LHV) was performed in 12 patients, and that of the LHV alone in four patients. Surgical techniques based on anatomical landmarks and histological findings are presented with videos. Histological confirmation of the anatomical landmarks for these procedures was performed in fresh cadavers to understand the anatomical structures and layers involved.

RESULTS

The median procedure duration was 15 (6-25) minutes. All procedures were performed safely with no major bleeding. Histological findings showed fibrous connective tissue between the tunica adventitia of the inferior vena cava (IVC) and the Laennec's capsule of the liver. The layer of dissection was along the tunica adventitia of the IVC.

CONCLUSIONS

The surgical techniques for encircling and taping of the common trunk of the MHV and LHV and the LHV alone based on anatomical landmarks were feasible and could allow for efficient outflow control in laparoscopic hepatectomy.

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.

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.

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

BACKGROUND

The liver hanging maneuver is a novel and useful technique that is widely used in open liver resections. The present study describes the surgical technique and outcomes of a modified liver hanging maneuver for pure laparoscopic left hemihepatectomy.

METHOD

The clinical data of patients who underwent laparoscopic left hemihepatectomy using a modified hanging technique were retrospectively reviewed. The upper end of the hanging tape was placed on the lateral side of the left hepatic vein. The pathway of the tape was situated along the ligamentum venosum.

RESULTS

Sixteen patients underwent pure laparoscopic left hemihepatectomy with the modified hanging technique. The median operation time was 225 min (range 180-300 min), with a median blood loss of 265 ml (range 140-600 ml). Postoperative major complications occurred in one patient (6.3%). The median postoperative hospital stay was 8 days (range 5-15 days). There was no postoperative liver failure or mortality.

CONCLUSION

This modified liver hanging maneuver is a simple, safe, and reproducible approach as dissection of between the middle and left hepatic vein is not required. This technique may be useful in laparoscopic left hemihepatectomy.