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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_775_Библиотеки_им_академика_М_И_Перельмана.pdf
274
K. Mishima et al.
a
VOLUME (cc) %LIVER AREA
To tal Liver Volume
Remnant Liver Volume
Right Lobe
S8
S8 Dorsal
S8 Vental
S7
S6
S5
1274 cc
1077 cc
821 cc
196 cc
165 cc
31 cc
189 cc
203 cc
233 cc
100%
84.6%
64.4%
15.5%
13%
2.5%
14.8%
15.9%
18.2%
def
Fig. 34.2 Preoperative planning for Lap-PSAH [22]
Laennec’s capsule theory [25]. Clear boundary can be visualized not only liver surface but also in the deep liver parenchyma (=intersegmental plane) during parenchymal
3. Parenchymal transection along with intersegmental plane
after ICG administration
4. Dissection of the G234 and LHV with linear stapler
transection.
cb
34.7.1 Laparoscopic Left Hemihepatectomy
(Fig.34.3)
1. Mobilization of the left lobe and encircling left hepatic
vein (LHV)
2. Encircling and clamping of the Glissonian pedicle
(G234)
34.7.2 Lap-PSAH (Segment 7) (Fig.34.4)
1. Mobilization of the right lobe and dissection of short
hepatic veins
2. Cholecystectomy and Encircling and clamping of the
Glissonian pedicle (G7)
3. Parenchymal transection after ICG administration
4. Dissection of the G7 and parenchymal transection along
with RHV or on the intersegmental plane
34 Laparoscopic Major Hepatectomy andParenchymal-Sparing Anatomical Hepatectomy
275
Fig. 34.3 Surgical Procedures of Laparoscopic Left Hemihepatectomy
276
Fig. 34.4 Surgical Procedures of Anatomical Segment 7 Resection
K. Mishima et al.
34.8 Conclusion
LMH still remains technically demanding, but it has been
gradually developed with the improvement of surgical techniques and the careful expansion of indications. Lap-PSAH
shares some surgical techniques with LMH and may help
shorten the learning curve of LMH. Long-term outcomes
should be evaluated in the future.
Conicts of Interest The authors have no conicts of interest to
declare.
Ethical Statement The authors are accountable for all aspects of
the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and
resolved.
References
1. Wakabayashi G, Cherqui D, Geller DA, Buell JF, Kaneko H, Han
HS, et al. Recommendations for laparoscopic liver resection: a
report from the second international consensus conference held in
Morioka. Ann Surg. 2015;261(4):619–29.
2. Dagher I, O’Rourke N, Geller DA, Cherqui D, Belli G, Gamblin
TC, etal. Laparoscopic major hepatectomy: an evolution in standard of care. Ann Surg. 2009;250(5):856–60.
3. Reich H, McGlynn F, DeCaprio J, Budin R.Laparoscopic excision of benign liver lesions. Obstet Gynecol. 1991;78(5 Pt
2):956–8.
4. Buell JF, Cherqui D, Geller DA, O’Rourke N, Iannitti D, Dagher I,
etal. The international position on laparoscopic liver surgery: the
Louisville statement, 2008. Ann Surg. 2009;250(5):825–30.
5. Ban D, Tanabe M, Ito H, Otsuka Y, Nitta H, Abe Y, et al. A
novel difculty scoring system for laparoscopic liver resection. J
Hepatobiliary Pancreat Sci. 2014;21(10):745–53.
6. Wakabayashi G. What has changed after the Morioka consensus
conference 2014 on laparoscopic liver resection? Hepatobiliary
Surg Nutr. 2016;5(4):281–9.
7. Wakabayashi G, Cherqui D, Geller DA, Han HS, Kaneko H, Buell
JF. Laparoscopic hepatectomy is theoretically better than open
hepatectomy: preparing for the 2nd international consensus conference on laparoscopic liver resection. J Hepatobiliary Pancreat Sci.
2014;21(10):723–31.
8. Ban D, Tanabe M, Kumamaru H, Nitta H, Otsuka Y, Miyata H,
etal. Safe dissemination of laparoscopic liver resection in 27, 146
cases between 2011 and 2017 from the National Clinical Database
of Japan. Ann Surg. 2020;274(6):1043–50.
9. Strasberg SM.Nomenclature of hepatic anatomy and resections:
a review of the Brisbane 2000 system. J Hepato-Biliary-Pancreat
Surg. 2005;12(5):351–5.
10. Di Fabio F, Samim M, Di Gioia P, Godeseth R, Pearce NW, Abu
HM. Laparoscopic major hepatectomies: clinical outcomes and
classication. World J Surg. 2014;38(12):3169–74.
11. Reddy SK, Barbas AS, Turley RS, Steel JL, Tsung A, Marsh JW,
etal. A standard denition of major hepatectomy: resection of four
or more liver segments. HPB (Oxford). 2011;13(7):494–502.
12. Cheek SM, Sucandy I, Tsung A, Marsh JW, Geller DA.Evidence
supporting laparoscopic major hepatectomy. J Hepatobiliary
Pancreat Sci. 2016;23(5):257–9.
13. Brown KM, Geller DA.What is the learning curve for laparoscopic
major hepatectomy? J Gastrointest Surg. 2016;20(5):1065–71.
14. Takahara T, Wakabayashi G, Konno H, Gotoh M, Yamaue H,
Yanaga K, et al. Comparison of laparoscopic major hepatectomy
with propensity score matched open cases from the National
Clinical Database in Japan. J Hepatobiliary Pancreat Sci.
2016;23(11):721–34.
15. Chen K, Pan Y, Hu GY, Maher H, Zheng XY, Yan JF.Laparoscopic
versus open major hepatectomy for hepatocellular carci-
34 Laparoscopic Major Hepatectomy andParenchymal-Sparing Anatomical Hepatectomy
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noma: a meta-analysis. Surg Laparosc Endosc Percutan Tech.
2018;28(5):267–74.
16. Wang ZY, Chen QL, Sun LL, He SP, Luo XF, Huang LS, etal.
Laparoscopic versus open major liver resection for hepatocellular
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cohort studies. BMC Cancer. 2019;19(1):1047.
17. Makuuchi M, Hasegawa H, Yamazaki S.Ultrasonically guided subsegmentectomy. Surg Gynecol Obstet. 1985;161(4):346–50.
18. Takasaki K, Kobayashi S, Tanaka S, Saito A, Yamamoto M,
Hanyu F.Highly anatomically systematized hepatic resection with
Glissonean sheath code transection at the hepatic hilus. Int Surg.
1990;75(2):73–7.
19. Hasegawa K, Kokudo N, Imamura H, Matsuyama Y, Aoki T,
Minagawa M, etal. Prognostic impact of anatomic resection for
hepatocellular carcinoma. Ann Surg. 2005;242(2):252–9.
20. Zhao H, Chen C, Gu S, Yan X, Jia W, Mao L, etal. Anatomical versus non-anatomical resection for solitary hepatocellular carcinoma
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Association of remnant liver ischemia with early recurrence and
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et al. Parenchymal sparing anatomical liver resections with full
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23. Takasaki K. Glissonean pedicle transection method for hepatic
resection: a new concept of liver segmentation. J Hepato-BiliaryPancreat Surg. 1998;5(3):286–91.
24. Hüscher CG, Lirici MM, Chiodini S.Laparoscopic liver resections.
Semin Laparosc Surg. 1998;5(3):204–10.
25. Sugioka A, Kato Y, Tanahashi Y.Systematic extrahepatic Glissonean
pedicle isolation for anatomical liver resection based on Laennec's
capsule: proposal of a novel comprehensive surgical anatomy of the
liver. J Hepatobiliary Pancreat Sci. 2017;24(1):17–23.
Laparoscopic Anatomical Resection
oftheLiver: Segmentectomy
andSub-segmentectomy
BoramLee andHo-SeongHan
35
Abstract
Laparoscopic liver resection (LLR) is rapidly increasing,
and certain types of resection are considered standard
procedures for liver resection. However, laparoscopic
anatomical resection (AR) is still challenging procedure,
because it requires precise parenchymal liver resection
along the anatomic landmark. Operation difculty varies
depending on the location of the resection area. The aim
of in this chapter is to provide important technical features of laparoscopic AR for each segment (I-VIII) using
Glissonean pedicle approach.
Anatomical liver resection (AR) involves resection of the
tumor and entire hepatic parenchymal tissue corresponding
to the portal veins draining the tumor [1]. Although the outcomes of AR are still debated, several reports suggested
that it is the best way to prevent intrahepatic metastasis
occurring via portal tributaries [2, 3]. There are two main
types of AR techniques, the Glissonean pedicle approach
and transection guided by dye injection into the portal
venous branches [4]. The Glissonean pedicle approach is
based on the three ramications of the Glissonean pedicle,
namely the left, middle, and right, as initially proposed by
Takasaki [5]. According to Takasaki’s classication, each
segment has one secondary branch of the Glissonean pedicle. Therefore, for resection any one of the segments, the
rst step is to cut the corresponding segmental branch of
the Glissonean pedicle and then dissect the liver parenchyma along the intersegmental plane [5, 6]. Makuuchi
etal. [7] propose the anatomical resection with ultrasoundguided dye injection. In this method, the tumor-bearing
portal pedicle is punctured and dye is injected under ultra-
sound guidance [7]. The stained area must be carefully
marked with eletrocautery, and transection should gradually proceed from the liver surface towards the portal pedicle stained by dye [1, 7].
Since rst report in 1992, laparoscopic liver resection
(LLR) is rapidly increasing, and certain types of LLR have
become standard procedures. However, laparoscopic AR is
still considered challenging procedure, because it usually
requires precise parenchymal liver resection using Glissonean
approach [8]. Laparoscopic Glissonean pedicle approach is
technically difcult because manipulation of laparoscopic
instruments for isolation of the pedicles is not easy due to
limitation on degree of freedom. Laparoscopic isolation of
the Glissonean pedicle before parenchymal liver resection
was rst reported by HS Han etal. in 2006 [9]. In that study,
the authors acknowledged the importance of the Glissonean
pedicle approach in laparoscopic AR.Since then, studies of
various types of laparoscopic AR through the Glissonean
pedicle approach have been reported (Fig.35.1) [10].
According to practical guidelines for performing LLR,
the difculty is divided by location of the resection area [8].
The peripheral portion of the anterolateral segments of the
liver (Segment 2,3,5,6, and the inferior part of segment 4) is
considered as safe location for performing LLR [8, 11–13].
Whereas, the posterosuperior portion of the liver (Segment
1, 7, 8, and the superior part of segment 4) is regarded as an
unfavorable location for performing LLR [14]. Our aim in
this chapter is to describe the operation techniques of
Laparoscopic AR for each segment (I-VIII), which is anatomic segementectomy.
35.1 Patient Position andTrocar Placement
B. Lee · H.-S. Han (*)
Department of Surgery, Seoul National University College of
Medicine, Seoul National University Bundang Hospital,
Seoul, South Korea
e-mail: hanhs@snubh.org
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Makuuchi et al. (eds.), The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases,
https://doi.org/10.1007/978-981-19-0063-1_35
The patient’s position and trocar placement can vary depending on the location of the tumor. The patient is placed in a
supine position or left semi-decubitus position with the surgeon standing on either right or left side, or the patient can be
279
280
lissonian concept was esteblished
G
1990
1st laparoscopic liver resection
1992
Complete Isolation of Glissonean Pedicle
17 18
1
Rt. post. sectionectomy
2006
Rt. & Lt.hepatectomy
2007
Major hepatectomy
2008
Various types of monosegmentectolmy
2009
B. Lee and H.-S. Han
19
26
20
22 23 24
Rt. ant. sectionectomy
2012
25
1990
1993 1996 1999 2002 2005 2008
Inthrahepatic Glissonian access in open surgery
2003
2011 2014
Rt. tri-sectionectomy
2009
Lt. hepatectomy and Lt. lateral sefctionectomy
2009
Rt. bisegmentectomy (VI&VII)
2008
Rt.hepatectomy
2007
Transparenchymal Clamp of Glissonean Pedicle
Fig. 35.1 Development of the Glissonean pedicle approach in laparoscopy (HS Han, YR Choi etal. [10])
35.2 Laparoscopic Segmentectomy I(S1)
Laparoscopic anatomic caudate lobectomy is considered as
difcult procedure due to its close proximity to major vessels
[15]. Caudate lobe is located in the deep dorsal area of the
liver between the portal triad and the inferior vena cava
(IVC) [16]. According to Kumon’s nomenclature, the caudate lobe consists of three sections; the Spiegel lobe, the
paracaval portion (Segment IX), and the caudate process
[17]. Trocar placement is shown in Fig.35.3.
After mobilization of the liver, the left liver is retracted
upward and the lesser omentum is opened to expose the S1.
Counter-demarcation method is used for S1 segmentectomy in our institution. The right posterior Glissonian pedicle is isolated and temporarily clamped with a bulldog
clamp [18]. The counter-demarcated line between caudate
Fig. 35.2 Routine Trocar placement
placed in a lithotomy position with the surgeon standing
between the legs of the patient.
The placement of trocar in LLR is important. Usually, ve
or six trocars are used. Two trocars for operator are placed
along the right subcostal line, and two other trocars for assistant are placed at the end of xyphoid process and at the left
upper quadrant of the abdomen. Figure35.2 shows the illustration of routine trocar placement.
process and the right posterior section is marked with electrocautery. The posterior surface of the caudate lobe is
freed from the IVC and the short hepatic veins are clipped
and cut. During parenchymal dissection, peripheral part of
the right hepatic vein (RHV) can be identied and is well
exposed meticulously. Dissection of the paracaval portion
is continued along the RHV.Resected caudate process and
the paracaval portion are retracted to the left side, the middle hepatic vein is identied, and parenchymal transection
is performed exposing the vein. With further parenchymal
36
34 35
31 32 33
30
29
35 Laparoscopic Anatomical Resection oftheLiver: Segmentectomy andSub-segmentectomy
In laparoscopic S3 segmentectomy, the Glissonean pedicle to S3 is exposed and divided on the left side of the round
ligament in the umbilical fossa. Then, the parenchymal dissection is begun along the demarcation line, exposing the left
hepatic vein [22]. Parenchymal dissection is performed
along the left hepatic vein with the same technique as S2
segmentectomy.
35.4 Laparoscopic Segmentectomy IV (S4)
(Subsegmentectomy IVa andIVb)
Left hemihepatectomy is generally performed for tumors
located in S4. However, the anatomical S4 segmentectomy
has the advantage that the remaining volume of the liver can
be preserved as much as possible. This operation is a technically demanding operative procedure because it has two
transection planes along two ssures, which are the course of
the main hepatic veins [23]. Therefore, it is important to
maintain a proper transection line to preserve the vascular
structures that supply the remnant liver. S4 can be subdivided
into the superior S4a and inferior S4b regions. Anatomical
S4a or S4b resection may also be advantages for a tumor that
Fig. 35.3 Trocar placement for laparoscopic S1 segmentectomy
dissection and division of the portal branches to the
Spigelian lobe, the completely caudate lobe is resected.
35.3 Laparoscopic Segmentectomy II (S2)
andSegmentectomy III (S3)
When the tumor is located in S2 or S3, laparoscopic anatomic S2 or S3 segmentectomy can be performed [19].
Segment-oriented hepatic resection on S2 or S3 has the
advantage of removing the disease-bearing liver segment,
and at the same time, preserving the vascular supply and biliary drainage of the liver remnant [20]. This concept is important in patients with underlying liver disease to prevent
postoperative liver failure [21]. With use of the Glissonean
approach to control the pedicle, anatomical resection can be
achieved.
For laparoscopic S2 segmentectomy, after mobilization of
left lateral section, the Glissonean pedicle to S2 is isolated
via meticulous dissection. Then, the Glissonean pedicle to
S2 is temporarily clamped. The ischemic margin of S2 is
marked using electrocautery. Transection of the liver parenchyma is performed thereafter. The liver parenchyma is dissected along the left hepatic vein with the guide of exposing
left hepatic vein. The portal pedicle to S2 is divided, and the
branches of hepatic veins draining S2 are encountered and
clipped along the left hepatic vein.
is conned to S4a or S4b [24].
The falciform ligament and coronary ligament are dissected in the cephalic direction until the middle and left
hepatic veins are visualized. The medial resection margin is
marked along the right side of the falciform ligament, after
which transection of the on the medial side is begun. The
supercial hepatic parenchyma is transected, and the deeper
portion of the parenchyma is dissected, until the inferior
vena cava and conuence of left and middle hepatic vein are
reached. Intrahepatic approach is used to control the
Glissonean pedicle to S4. When performing the subdivisional Glissonean peidcle to S4a or S4b, we have to dissect
to more peripherally to enable identication and isolation of
each S4a and S4b pedicle. To conrm the correct identication, we have to check for an ischemic color change in the
corresponding area after temporarily clamping the S4a or
S4b pedicle.
For S4a segmentectomy, the S4a Glissonean pedicle is
isolated and ligated. After division of S4a pedicle, the liver
parenchyma is dissected along the areas of demarcation on
the liver surface, exposing the middle hepatic vein (MHV)
toward its conuence with the inferior vena cava (IVC).
For S4b segmentectomy, the S4b Glissonean pedicle is
isolated and cut. The liver parenchyma is dissected along the
boundary of the demarcated region. Segmentetctomy 4 can
be performed by combing the techniques for S4a and S4b.
After cutting the S4 Glissonian pedicle, an area of S4 is discolored due to ischemia. For completion of S4 resection,
parenchymal transection on right side is performed along
ischemic line along the middle hepatic vein.
281
282
B. Lee and H.-S. Han
35.5 Laparoscopic Segmentectomy V (S5)
When the tumor is located in S5, there are several options.
One is anatomical major resection such as, right hemihepatectomy, right anterior sectionectomy, and central segmentectomy [25]. Another option is nonanatomical resection
such as wedge resection and tumorectomy. The remaining
option is anatomical S5 resection.
After cholecystectomy, the Glissonean pedicle to the right
anterior section is isolated by meticulous dissection. With a
temporary clamp of the right anterior Glissonean pedicle, the
ischemic margin of the right anterior section is marked.
Transection of the liver parenchyma at the medial margin is
started. As the right anterior Glissonean pedicle is further
dissected peripherally, the Glissonean pedicle to S5 can be
isolated and then, discolored S5 area is marked after temporary clamping of S5 Glissonean pedicle. Selective isolation
of the Glissonean pedicle to S5 is crucial in anatomical S5
segmentectomy, as there are no anatomical landmarks for S5
segmentectomy. After the S5 Glissonean pedicle is divided,
parenchymal transection at the lateral and superior side of
the S5 is performed.
35.6 Laparoscopic Segmentectomy VI (S6)
The small tumor located peripherally in S6 is one of the easily approachable method for LLR like tumorectomy.
However, anatomical resection of S6 is complex even in
open surgery, thus a laparoscopic resection of S6 is also a
challenging procedure [26].
Before the parenchymal dissection, the right liver is mobilized from the diaphragm and right adrenal gland as in the
open approach. After cholecystectomy, the Glissonean pedicle to the right posterior section is dissected and isolated.
Further hepatic parenchymal dissection is performed until
the branches of the Glissonean pedicles of S6 and segment 7
(S7) is identied. Temporary clamping of the Glissonean
pedicle of S6 is performed for conrmation the demarcation
of S6 based on ischemic line. The S6 Glissonean pedicle is
then divided with clips or stapler. After marking of ischemic
line of S6, parenchymal transection is performed.
formed until the branches of the Glissonean pedicles of S6
and S7 are reached. The S7 Glissonean pedicle is temporarily clamped to conrm demarcation. Dissection is performed
until the right hepatic vein (RHV) is exposed. Further dissection is then continued along the RHV.Second, laparoscopic
S7 segmentectomy through RHV rst approach [29]. After
fully mobilization of right liver, rotate the whole liver completely to the left side to approach to the root of RHV.Before
the parenchymal dissection, the RHV is encircled by vessel
loop to prepare for massive bleeding. Parenchymal transection starts from the conuence of hepatic vein and then, followed along RHV with ligating small branches
RHV.Dissection is performed until the Glissonean pedicles
of S7 is exposed. Then, the S7 Glissonean pedicle is temporarily clamped to conrm demarcation.
When performing the laparoscopic anatomical S7 segmentectomy, the operative eld is difcult to obtain with the
use of conventional trocar site. And laparoscope and the
instrument need to be advanced backward and forward over
a longer distance [30, 31]. Therefore, additional ports
inserted through the intercostal space (ICS) will be benecial in overcoming these difculties [32]. Additional intercostal ports are placed at the 7th and 9th ICS (Fig. 35.4).
When using intercostal trocars, we should be careful to avoid
intercostal vessel bleeding. Intercostal trocars can be helpful
to easily access the operative eld and manipulate the instruments (Fig.35.5).
35.7 Laparoscopic Segmentectomy VII (S7)
Laparoscopic liver resection for tumors located in S7 is a
challenging procedure [27]. There are several methods for
anatomoical S7 resection. First, laparoscopic anatomical S7
segmentectomy via the intrahepatic Gissonean approach
[28]. After full mobilization of right liver, the major
Glissonean pedicle of the right posterior section is dissected
and isolated. Further hepatic parenchymal dissection is per-
Fig. 35.4 Trocar placement for intercostal space
35 Laparoscopic Anatomical Resection oftheLiver: Segmentectomy andSub-segmentectomy
5. Takasaki K. Glissonean pedicle transection method for hepatic
resection: a new concept of liver segmentation. J Hepato-BiliaryPancreat Surg. 1998;5(3):286–91.
6. Yamamoto M, Katagiri S, Ariizumi S, Kotera Y, Takahashi
Y. Glissonean pedicle transection method for liver surgery (with
video). J Hepatobiliary Pancreat Sci. 2012;19(1):3–8.
7. Makuuchi M, Hasegawa H, Yamazaki S.Ultrasonically guided sub-
segmentectomy. Surg Gynecol Obstet. 1985;161:346–50.
8. Cho JY, Han HS, Wakabayashi G, Soubrane O, Geller D, O’Rourke
N, et al. Practical guidelines for performing laparoscopic liver
resection based on the second international laparoscopic liver consensus conference. Surg Oncol. 2018;27:A5–9.
9. Yoon YS, Han HS, Choi YS, etal. Total laparoscopic right posterior
sectionectomy for hepatocellular carcinoma. J Laparoendosc Adv
Surg Tech A. 2006;16(3):274–7.
10. Choi Y, Han HS, Sultan AM, Yoon YS, Cho JY. Glissonean ped-
Fig. 35.5 Operative view of laparoscopic segmentectomy VII (S7)
using intercostal trocar
35.8 Laparoscopic Segmentectomy
VIII(S8)
Laparoscopic anatomical S8 resection is still rarely performed due to its unfavorable location for laparoscopic
approach and technical difculties [32].
After fully mobilization of right liver, the roots of right
and middle hepatic vein are identied. After isolation of the
right main Glissonean pedicle, the pedicle isolation is continued until the right anterior Glisssonean pedicle is exposed.
Then, Glissonean pedicle is further dissected to expose the
Glissonean pedicles of S8, and the pedicle is temporarily
clamped. After the area of the segment 8 is identied with
ischemic discoloration, resection of hepatic parenchyma is
started [33]. Once part of MHV (MHV) is exposed, parenchymal resection is proceeded along the plane of the MHV
until its root is exposed. Posterior side of the S8 is detached
from the IVC with the retraction of S8 to left side. To save
the parenchyma as much as possible, the dissection plane is
performed along the right hepatic vein. Parenchymal transection is performed until conuence of the right hepatic
vein to IVC is reached.
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