Laparoscopic Anatomical Resection of Paracaval Portion of Caudate Lobe and Segment 8 for HCC in an HCV-Related Cirrhotic Patient

BACKGROUND

Laparoscopic anatomical resection of caudate lobe remains poorly described due to deep location and connection with major vascular structures. The anterior transparenchymal approach might be safter and provide a better surgical view in cirrhotic cases.1,2 This report demonstrated this approach for anatomic laparoscopic resection of paracaval portion and segment eight (S8) for HCC in an HCV-related cirrhotic patient.

METHODS

A 58-year-old man was admitted. The preoperative magnetic resonance imaging indicated that the mass with pseudo capsule was located in paracaval portion and S8 closed to IVC, RHV, and MHV with atrophic left lobe. The preoperative ICG-15R test was 16.2%. In this regard, right hemihepatectomy combined with caudate resection was aborted. We decided to perform an anatomical resection via anterior transparenchymal approach to reserve liver parenchyma as much as possible.3,4 RESULTS: After right lobe mobilization and cholecystectomy, the anterior transparenchymal approach was performed along Rex-Cantlie line by using Harmonic (Johnson & Johnson, USA). With the dissection and clamping of the Glissonean pedicles of S8, anatomical segmentectomy was performed according to the ischemic line and parenchymal transection was performed along hepatic veins. Finally, paracaval portion combined with S8 was en bloc resected. The operating time was 300 minutes with 150 ml of blood loss. The histopathologic report demonstrated the mass as HCC with negative resection margin. Furthermore, it showed a medium-to-high differentiation with no MVI and no microscopic satellite.

CONCLUSIONS

The anterior transparenchymal approach for anatomic laparoscopic resection of paracaval portion and S8 might be a feasible and safe option for severe cirrhotic cases.

Laparoscopic liver resection of segment 8 via a hepatic parenchymal transection-first approach guided by the middle hepatic vein

Background

Pure laparoscopic liver resection (LLR) of segment 8 (S8) is still rarely performed due to the lack of an appropriate surgical approach. This article discusses the technical tips and operation methods for LLR of S8 via a hepatic parenchymal transection-first approach.

Methods

Clinical data of 22 patients who underwent LLR of S8 via a hepatic parenchymal transection-first approach guided by the middle hepatic vein (MHV) in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from May 2017 to February 2020 were retrospectively analyzed.

Results

The mean age was 51.1 ± 11.6 years; mean operation time, 186.6 ± 18.4 min; median blood loss, 170.0 ml (143.8–205.0 ml); and median length of hospital stay, 8.0 days (7.0–9.0 days). There was no case of open conversion. Pathologic findings revealed all cases of hepatocellular carcinoma (HCC). Pathology showed free surgical margins. Post-operative complications included liver section effusion, pleural effusion, pneumonia, intra-abdomen bleeding and bile leak. All the complications responded well to conservative treatment. No other abnormality was noted during outpatient follow-up examination. All patients survived tumor-free.

Conclusions

LLR of S8 is still quite challenging at present, and it is our goal to design a reasonable procedure with accurate efficacy and high safety. We use hepatic parenchymal transection-first approach guided by the MHV for LLR of S8. This technique overcomes the problem of high technical risk, greatly reduces the surgical difficulty and achieves technological breakthroughs, but there are still many problems worth further exploration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02289-8.

All the Routes for Laparoscopic Liver Segment VIII Resection: A Comprehensive Review of Surgical Techniques

Liver surgery is highly demanding for anatomical, physiological and technical reasons, and minimally invasive approaches have been implemented at a slower rate. Today, laparoscopic liver resection is a standard of care in many occasions, yet specific operations remain particularly challenging and generally performed in open surgery. In particular, SVIII resection may be considered one of the most difficult due to anatomical characteristics including its sub-diaphragmatic position, the deep-lying Glissonean pedicle and the close contact with the inferior vena cava and right and middle hepatic veins. Many techniques have risen to overcome technical difficulties, and today laparoscopic SVIII resection has been demonstrated to be feasible. This review provides a complete picture of current approaches, focusing on all techniques reported so far with critical appraisal of each, discussing and explaining benefits and pitfalls.

Intrahepatic Glissonean Approach for Laparoscopic Bisegmentectomy 7 and 8 With Root-Side Hepatic Vein Exposure

BACKGROUND

Laparoscopic anatomic liver resections of the posterosuperior segments are technically demanding procedures.^1-5 The segments are located in a deep-seated area of the liver surrounded by the ribs and the diaphragm, making forceps manipulation difficult. To overcome this limitation, an intrahepatic Glissonean approach and exposure of the hepatic veins from the root side was applied.^6-10 The authors describe the technical aspects of performing a bisegmentectomy 7-8.

METHODS

Liver parenchymal transection was initiated from the ventral aspect of the root of the middle hepatic vein, which often runs in the intersegmental plane, identifying the Glissonean pedicle of segment 8 (G8). After dissection of the G8, segmentectomy 8 was performed through identification of the ischemic area. After complete mobilization of the right lobe, the Glissonean pedicle of segment 7 (G7), which runs relatively near the liver surface,^{9, 10} was marked using ultrasonography. After division of the G7, a wide dissection between the caudate lobe and segment 7 was performed and connected to the previously dissected plane from the dorsal side of the right hepatic vein (RHV). Finally, bisegmentectomy 7-8 was performed with RHV resection because of tumor invasion.

RESULTS

The operation time was 510 min, and the estimated blood loss was 150 ml. The patient was discharged on postoperative day 10 without any complications.

CONCLUSIONS

Application of the intrahepatic Glissonean approach and exposure of the major hepatic veins from their roots using unique laparoscopic principles allows a safe performance of bisegmentectomy 7-8.

Landmarks and techniques to perform minimally invasive liver surgery: A systematic review with a focus on hepatic outflow

PURPOSE

In this systematic review, we aimed to clarify the useful anatomic structures and assess available surgical techniques and strategies required to safely perform minimally invasive anatomic liver resection (MIALR), with a particular focus on the hepatic veins (HVs).

METHODS

A systematic review was conducted using MEDLINE/PubMed for English articles and Ichushi databases for Japanese articles through September 2020. The quality assessment of the articles was performed in accordance with the Scottish Intercollegiate Guidelines Network (SIGN).

RESULTS

A total of 3372 studies were obtained, and 59 were selected and reviewed. Due to the limited number of published comparative studies and case series, the degree of evidence from our review was low. Thirty-two articles examined the anatomic landmarks and crucial structures for approaching HVs. Regarding the direction of HV exposure, 32 articles focused on the techniques and advantages of exposing HVs from either the root or the periphery. Ten articles focused on the techniques to perform a segmentectomy 8 in particularly difficult cases of MIALR. In seven articles, bleeding control from HVs was also discussed.

CONCLUSIONS

This review may help experts reach a consensus regarding the best approach to the management of hepatic veins during MIALR.

Tailored Strategy for Dissecting the Glissonean Pedicle in Laparoscopic Right Anterior Sectionectomy: The Extrahepatic, Intrahepatic, and Transfissural Glissonean Approaches (with Video)

BACKGROUND

The Glissonean approach is a widely used anatomic liver resection technique, which can be divided into three types: the extrahepatic, intrahepatic, and transfissural approaches. This report describes the technical details and surgical outcomes of these laparoscopic right anterior sectionectomy (lap-RAS) approaches.

METHODS

Using the extrahepatic Glissonean approach, the posterior extremity of the cystic plate is dissected and divided. The hilar plate is detached from Laennec's capsule covering the liver parenchyma. The gap between the plate system and Laennec's capsule is entered. Without liver parenchymal transection, the right anterior Glissonean pedicle (RAGP) is dissected extrahepatically. Using the intrahepatic Glissonean approach, the posterior extremity of the cystic plate is divided, and the hilar plate is detached, which may decrease the visibility of the RAGP. The RAGP then is dissected intrahepatically through the minor parenchymal transection around the cystic plate. When the extra- or intrahepatic Glissonean approach fails, the transfissural Glissonean approach can be used, with the RAGP dissected through the major parenchymal transection along the main portal fissure.

RESULTS

Three patients underwent lap-RAS using the Glissonean approach. The median operation time was 330 min (range, 300-380 min), and the median estimated blood loss was 160 mL (range, 80-180 mL). No cases of postoperative morbidity or mortality were observed.

CONCLUSION

The feasibility of the Glissonean approach in lap-RAS could be increased by appropriate selection of the extrahepatic, intrahepatic, and transfissural Glissonean approaches.

Laparoscopic Anatomical Segmentectomy in Tertiary Portal Pedicles with Variations and Deep Location Using the Transfissural Glissonean Approach (Video)

BACKGROUND

The Glissonean pedicle approach is a widely used technique in anatomical liver resection1. The Glissonean pedicle approach can be divided into the extrafacial approach (conventional Glissonean approach) and the transfissural approach2,3,4. We present pure laparoscopic anatomical segmentectomy in tertiary portal pedicles with anatomical variations and a deep location using the transfissural Glissonean approach.

METHODS

According to the branching pattern of the tertiary portal pedicles, selection of the extrafascial or the transfissural approach was determined. The tertiary portal pedicles around the liver hilum can be dissected using the extrafascial approach. The transfissural approach was applied when the tertiary portal pedicles were multiple, variable, and located deep within the liver. These pedicles can be dissected after parenchymal transection along the fissure lines (resection of segment 6: right portal fissure; resection of segment 3: umbilical fissure).

RESULTS

Patients underwent anatomical resection of segments 6 (n = 8; extrafascial: 5; transfissural: 3) and 3 (n = 4; extrafascial: 1; transfissural: 3). The median operative time was 200 min (range 110-250 min), and the median blood loss was 100 mL (range 40-350 mL). The median tumor size was 18.5 mm (range 11-30 mm). All patients were negative resection margin. The median postoperative hospital stay was 5.5 days (range 4-8 days).

CONCLUSION

The tertiary portal pedicles can be dissected using the extrafascial or the transfissural approach. The transfissural approach in tertiary portal pedicles with anatomical variations and a deep location is a useful and effective method because opening the fissure lines allows direct access to these pedicles.

Pure Laparoscopic Anatomical Resection of Segment 4b for Hepatocellular Carcinoma Using the Transfissural Glissonean Approach

BACKGROUND

Anatomical segmentectomy is a technically challenging procedure because tertiary portal pedicles are multiple, variable, and deep inside the liver.¹ Anatomical segmentectomy can be performed using the transfissural Glissonean approach through the opening main portal fissure or umbilical fissure.^1-3 We present laparoscopic anatomical resection of segment 4b using the transfissural Glissonean approach.

METHODS

A 67-year-old man was referred for treatment of single nodular mass in segment 4b. The surgical procedure involved the following steps: (1) Opening of the umbilical fissure along the umbilical fissure vein (2) Dissection of Glissonean pedicle 4b (3) Identification of ischemic territory of segment 4b (4) Right-side parenchymal transection along the ischemic line.

RESULTS

The operative time was 230 min, and the estimated blood loss was 100 mL. The final histopathological diagnosis was hepatocellular carcinoma. The tumor size was 30 mm and the resection margin was 25 mm. The patient had an uneventful postoperative recovery, and he was discharged on postoperative day 6.

CONCLUSION

The transfissural Glissonean approach for laparoscopic anatomic resection of segment 4 b is a feasible and effective technique. The opening of the umbilical fissure allows the surgeon to dissect the target portal pedicles of segment 4b directly.

Laparoscopic anatomical segmentectomy using the transfissural Glissonean approach

BACKGROUND

Anatomical segmentectomy is a technically difficult procedure owing to the complexity of the segmental anatomy of the liver. In the conventional Glissonean approach from the liver hilum, the tertiary portal pedicles may be difficult to dissect because of their anatomical variations and deep location. We present a technique of purely laparoscopic anatomical segmentectomy of the liver using the transfissural Glissonean approach.

METHODS

We performed purely laparoscopic anatomical segmentectomy using the transfissural Glissonean approach. This approach involved initially opening the liver parenchyma along the fissure line (main portal, right portal, and umbilical fissures). Thereafter, the target tertiary portal pedicles were approached and ligated within the liver parenchyma above the liver hilum.

RESULTS

Between August 2014 and September 2019, we performed 17 cases of laparoscopic anatomical segmentectomy using the transfissural Glissonean approach. The median operative time was 200 min (range 120-310 min), and the intraoperative blood loss was 80 mL (range 30-280 mL). The median postoperative hospital stay was 6 days (range 3-9 days). There was no major morbidity or mortality.

CONCLUSION

The transfissural Glissonean approach in laparoscopic anatomical segmentectomy is technically feasible because opening the fissure allows direct access to the tertiary portal pedicles.