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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_794_Библиотеки_им_академика_М_И_Перельмана.pdf
Laparoscopic Liver Resection
Michael D. Kluger, Daniel Cherqui
Dierent laparoscopic resections require varying levels of expertise, but all require familiarity
with preoperative planning and perioperative care of the liver patient, open liver surgery, hepatic
anatomy, and advanced laparoscopic principles. e 2008 Louisville Statement divides these operations among pure laparoscopy, hand-assisted laparoscopy, and a hybrid technique. Pure laparoscopy involves complete mobilization and resection via laparoscopic ports, although an incision
may be used for specimen extraction. Hand-assisted laparoscopy involves the elective placement
of a hand-port for mobilization or resection, which is then used for specimen extraction. In the
hybrid technique, the resection is performed through a mini-laparotomy, though laparoscopy with
or without hand assistance is utilized for mobilization. Historically, about 25 % of liver resections
may be considered for a laparoscopic approach.
Indications and Contraindications
Indications
Contraindications
e indications for laparoscopic liver resection are the same as for open liver resections. Highquality MRI or CT imaging with vascular reconstruction should be reviewed to evaluate for intrahepatic arterial and portal anomalies and to determine if the lesion is amenable to a laparoscopic
resection.
Based on tumor size and location of the lesion, the following situations are most suitable for a
laparoscopic approach: 1) nonpedunculated lesions less than 5 cm in diameter; 2) pedunculated
lesions of any size that do not obscure safe working space; and 3) lesions located in the anterior
segments of the liver (Segments2–6;
ne c tomy.
Contraindications are mainly anatomical: 1) large, nonpedunculated tumors (> 5 cm in diameter); 2) lesions located in proximity to the major hepatic veins, the inferior vena cava, and
the hepatic hilum; 3) hilar cholangiocarcinoma, or inability to achieve a sucient margin for any
lesion; and 4) patient unlikely to tolerate or recover from an open operation because of chronic
medical conditions.
. Fig. 50.1), especially lesions requiring a le lateral sectio-
. Fig.50.1
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_50, © Springer-Verlag Berlin Heidelberg 2016
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5
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Section III • Liver: Nontransplant Procedures
Patient Position, Port Sites, and Case Preparation
For atypical and anatomical resections in segments2 through 5, right hepatectomy, le
-
hepatectomy, and le lateral sectionectomy: Supine position with lower limbs apart and ve
ports (
. Fig. 50.2a)
For limited resection of segment6: A le lateral decubitus position with three or four ports
-
may be considered (
All laparoscopic equipment should be state-of-the-art:
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A 10-mm 30°laparoscope with high-denition camera, xenon lighting, and high-deni-
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tion monitors improve the visual safety of the operation.
Comfortable, ergonomic laparoscopic instruments, including ratcheted, atraumatic
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bowel graspers, curved and right angle dissectors, scissors, needle holders, and a liver
retractor, are necessary.
Devices including laparoscopic staplers, ultrasonic dissector, ultrasonic shears or a
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vessel-sealing device, clip appliers, suction-irrigator, bipolar diathermy forceps, and a
monopolar diathermy hook are all critical.
B-mode and D-mode ultrasound and a high-frequency laparoscopic transducer probe
-
are required.
Low central venous pressure anesthesia
-
Low-pressure (12 mm Hg) CO2 pneumoperitoneum to prevent gas embolism
. Fig. 50.2b)
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. Fig.50.2
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Chapter • Laparoscopic Liver Resection
Procedures
A note on parenchymal transection: From a simplistic view, the operator dissects through three
layers of liver parenchyma perfused and drained by vascular and biliary structures of various
sizes. e rst layer, the capsule, is easily penetrated and made hemostatic using monopolar
diathermy. e second layer comprises the supercial 2 to 3 cm of parenchyma, which can be
transected with ultrasonic shears or a vessel-sealing device. For the deep parenchyma, dissection
is best accomplished with an ultrasonic dissector. Vascular and biliary structures encountered
during the dissection of the supercial and deep parenchyma are ligated and transected with
dierent devices based on their diameter. Vascular and biliary structures less than 3 mm are
ligated and transected using ultrasonic shears, a vessel-sealing device, or bipolar diathermy.
Larger structures such as the hepatic artery and bile ducts are ligated using plastic locking clips.
Laparoscopic staplers with 2.5 mm depth loads are used for Glissonian pedicles, portal branches,
and hepatic veins.
Procedure: Left lateral sectionectomy
is is the anatomic liver resection most commonly performed laparoscopically. It also illustrates
many of the techniques necessary for more dicult laparoscopic procedures.
Step1
Step2
Access, exploration, and mobilization of the left lateral section
Aer placement of the ports, the liver is explored by laparoscopic ultrasound to determine the
size and location of the tumor, to detect additional lesions, to assess the quality of surrounding
liver tissue, and to conrm the feasibility of a laparoscopic resection. First, the round ligament
is divided, and then the falciform ligament is divided down to the inferior vena cava where the
hepatic veins insert. Finally, the le triangular and coronary ligaments are divided and the lesser
omentum is opened. When present, an accessory or replaced le hepatic artery originating from
the le gastric artery should be ligated and divided. Additionally, a parenchymal bridge covering
the inferior aspect of the round ligament should be divided.
Preparation for the Pringle maneuver and parenchymal transection
If pedicle occlusion is anticipated, the pars accida is opened and an instrument is passed from
the most lateral right port behind the portal triad in order to encircle it with an umbilical tape
(. Fig. 50.3a). e ends of the tape are then extracorporeally passed through the lumen of a
16French rubber tube4 to 5 cm in length and returned to the abdomen. If pedicle clamping is
required, a laparoscopic instrument grasps the ends of the tape, pulling it taut, while a laparoscopic
locking clip applier pushes the tubing toward the pedicle and applies a clip, thereby maintaining
the Pringle (
Parenchymal transection follows the le margin of the round and falciform ligament from
the anterior edge of the le lateral section up to the level of the origin of the le hepatic vein. e
exposure during transection is maintained by traction of the round ligament superiorly and to
the right and traction of the le lateral segment superiorly and to the le, using atraumatic bowel
graspers (
falciform ligament, to avoid injury to the pedicles of Segment4. Posteriorly, the line of transection follows the anterior margin of Arantius’ ligament. e technique of parenchymal transection
includes division of the liver with step-by-step control and division of the encountered pedicles
(
. Fig. 50.4b). e parenchyma to be divided during a le lateral sectionectomy is usually thin
enough that ultrasonic shears or a vessel-sealing device is sucient for transection. ese devices
are also sucient for minor vessels up to 3 mm. Structures larger than 3 mm in diameter are
clipped before division. Portal pedicles to Segments2 and 3 are divided using two or three rings
of the linear stapler (.
e Pringle maneuver in . Fig. 50.3, 50.4, 50.5 is for purposes of demonstration, and is typically
unnecessary for le lateral sectionectomy.
. Fig. 50.3b). We favor 15min of clamping interrupted by 5min of pedicle ow.
. Fig. 50.4a). It is important that the line of transection remains on the le side of the
Fig. 50.5
). e stapler must be applied on the le side of the round ligament.
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Section III • Liver: Nontransplant Procedures
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. Fig.50.3
. Fig.50.4
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. Fig.50.5
Chapter • Laparoscopic Liver Resection
Step3
Transection of the left hepatic vein and extraction of the specimen
Once the portal pedicles have been divided, dissection progresses cephalad to identify the le hepatic vein, which can then be divided using a linear stapler, nishing the transection (.
Additional hemostasis of the transected surface can be achieved by monopolar or bipolar diathermy, clipping, or suturing.
Lesions can be removed through preexisting scars, or through a 5-cm Pfannenstiel incision
in the virgin abdomen (. Fig. 50.6b). Regardless of the chosen incision, the abdominal wall is
incised to the fascia and a 15-mm trocar is inserted at the center of the incision. A large-capacity
endoscopic bag is introduced and the specimen retained (.
retracted against the fascia, and the fascia and peritoneum are opened only as much as necessary
for retrieval. e fascial layers are anatomically approximated and the pneumoperitoneum is
reintroduced. e operative site is again examined for hemostasis and biliary stasis.
Fig. 50.6c
). e specimen is then
Fig. 50.6a
).
. Fig.50.6
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Section III • Liver: Nontransplant Procedures
Procedure: Non-anatomical resections
ese resections are for small lesions located on the edge of the anterolateral segments of the
liver. e liver is exposed and explored as for a le lateral sectionectomy; ligaments need to be
transected only if it will improve exposure. Although a Pringle maneuver is rarely necessary for
these resections, it is a safety measure to prepare for the possibility of bleeding. Resection limits are
marked on the liver surface with diathermy aer ultrasonography conrmation (.
margins are not required for benign lesions, but a 10-mm margin is recommended for malignant
tumors of the liver. Dissection should proceed circumferentially at equal depths. Dissecting a hole
in one area should be avoided, because depth may be underappreciated and vascular or biliary
structures inadvertently violated. A 4-0Prolene suture can be used to li the lesion away from the
surrounding parenchyma to promote circumferential, consistent-depth dissection.
Parenchymal transection follows the margins marked on the liver surface by diathermy. Because this is a peripheral resection, either the ultrasonic shears or a vessel-sealing device is sufcient. Additional hemostasis is achieved by bipolar diathermy and according to the size of the
encountered pedicles. Staplers are usually unnecessary except for pedunculated lesions, whose
pedicles can be divided by stapler applications. Depending on lesion size, the specimen is extracted
through extension of a port incision or in the same way as for the le lateral sectionectomy.
Fig. 50.7
). Wide
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. Fig.50.7
Procedure: Laparoscopic right hepatectomy
is procedure can be performed from an anterior or conventional approach. Although the hilar
dissection is the same for both approaches, the conventional approach entails extensive pretransection mobilization and extrahepatic control of the right hepatic vein; the use of a hand-port
may be useful in this setting. Additionally, hand-assisted laparoscopy can be utilized as needed
for failure of case progression or to aid in obtaining hemostasis. A gas-tight port is placed in the
right lower quadrant and the incision is later used for specimen extraction (
laparoscopic anterior approach is described below.
. Fig. 50.8). e pure
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. Fig.50.8
Chapter • Laparoscopic Liver Resection
Step1
Access, exploration, mobilization, and vascular control
Ports are placed and the round and falciform ligaments are transected as previously described;
ultrasonography is performed. Aer partial cholecystectomy, the distal cystic duct is retracted to
the patient’s le and the gallbladder to the right, exposing the short course of the extrahepatic right
pedicle. If the patient has had a prior cholecystectomy, the right and le hemilivers are retracted
using atraumatic graspers. e right hepatic artery is circumferentially dissected for a distance of
1 to 2 cm and encircled with a tape to retract it away and protect the other hilar structures. e
right hepatic artery is divided between plastic locking clips (
visualized posterior to the artery and dissected and taped in a similar manner. e bifurcation and
le portal branch must be clearly visualized (.
with a linear stapler, the tape should be pulled to the patient’s le, to displace the bifurcation to
the le and lengthen the right branch (
prevents narrowing of the le portal branch. It will oen be necessary to ligate a portal branch
from the right portal vein to the anterior-right side of Segment1 with an electrosurgical device
to safely dissect the right portal branch.
. Fig. 50.9c). Plastic locking clips may also be placed. is
Fig. 50.9b
. Fig. 50.9a). e right portal vein is
). When transecting the right portal vein
Step2
. Fig.50.9
Parenchymal transection
e extrahepatic vessel ligation delimits the plane of ischemia and thus transection, and is outlined on the liver capsule with monopolar diathermy. Parenchymal transection is started at the
inferior edge of the liver in the anterior-to-posterior and caudad-to-cephalad directions along
the demarcation line. At the hilar plate, the right bile duct is circumferentially dissected until the
anterior and posterior branches are visualized, at which point the duct can be divided with locking
clips or the stapler. Division of the hilar plate allows the dissection plane to be opened wide for
easier parenchymal transection. It will be necessary next to divide the connective tissue junction
between the right lobe and Segment1 with electrosurgery to fully expose the retrohepatic cava.
As parenchymal transection progresses, Glisson’s capsule is divided along the anterior surface of
the cava, with systematic clipping and dividing of the small bridging veins.
Section III • Liver: Nontransplant Procedures
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Step3
Transection of the right hepatic vein and extraction of the specimen
As progress is made cranially, the proximal hepatic veins draining segments5 and 8 toward the
middle hepatic vein are exposed, clipped, and divided. e right hepatic vein is identied at its
insertion into the cava, taped, retracted to the patient’s right, and transected with an articulating linear stapler (
coronary ligaments are divided from the diaphragm with electrosurgical instruments, and then
retracted to the le as the cava and hepatocaval ligament are divided with clips and staplers. e
specimen is removed as previously discussed. For right hepatectomy, a 10French closed-circuit
suction drain is placed in the subphrenic space.
. Fig. 50.10). e specimen is now retracted to the right as the triangular and
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. Fig.50.10
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Chapter • Laparoscopic Liver Resection
Procedure: Laparoscopic left hepatectomy
Step1
Access, exploration, mobilization, and vascular control
Ports are placed and the round and falciform ligaments are transected as previously described;
ultrasonography is performed. e le triangular and coronary ligaments are divided close to the
liver from laterally to medially, as is the attachment of the lesser omentum. e le lateral segment is mobilized and the suprahepatic cava cleared of brous tissue so that the insertions of the
hepatic veins into the vena cava are identied. e peritoneum above the caudate is next opened
to expose the cava and the insertion of the le hepatic and middle veins. If a replaced or accessory
le hepatic artery is present, it should be transected between clips.
e extrahepatic le Glissonian pedicle is exposed and carefully dissected using endoscopic
scissors and bipolar diathermy. e le hepatic artery and le portal vein are individually isolated
using right-angled forceps (. Fig. 50.11), elevated with umbilical tapes, and ligated with locking
clips and a linear stapler, respectively.
Step2
. Fig.50.11
Parenchymal transection
Parenchymal transection proceeds anterior-to-posterior and caudad-to-cephalad. Once dissection
enters the hilar plate, the le bile duct is divided with a linear stapler or between clips. Parenchymal
transection continues cranially until the insertion of the le hepatic vein into the common trunk,
at which point it is transected using an articulating stapler without encroaching upon the middle
hepatic vein. Parenchymal transection is completed and the specimen is removed as previously
discussed.
Procedure: Laparoscopic living-donor left lateral sectionectomy
is procedure consists of a laparoscopic le lateral sectionectomy without early vascular clamping
or division in order to minimize parenchymal ischemia. General principles of patient preparation,
instrumentation, and mobilization are the same as for the le lateral sectionectomy.
Section III • Liver: Nontransplant Procedures
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Step1
Step2
Preparation of the left portal pedicle
e le arterial and portal branches are dissected in the hepatoduodenal ligament as discussed
for le hepatectomy, and encircled with a vessel loop, as was demonstrated in the previous gure for le hepatectomy. Arterial and portal branches to Segment1 are divided between clips
(. Fig. 50.12).
. Fig.50.12
Parenchymal transection
In contrast to the conventional resection of the le lateral section, the parenchymal transection
for living donation needs to be performed along the right of the falciform ligament. Ultrasonic
shears or a vessel-sealing device is used for the supercial part of the transection, and an ultrasonic
dissecting device is necessary for the deeper transection. Bleeding is controlled by using bipolar
diathermy and clips, without vascular clamping. Segment4 portal pedicles are divided inside the
liver parenchyma with locking clips.
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Step3
Left bile duct division
Once parenchymal transection has reached the hilar plate and the le hepatic duct becomes
visible, the le bile duct proximal to the Segment4 insertion is divided using sharp scissors
(.
Fig. 50.13
with the gra stump being le patent.
. Fig.50.13
). e remnant stump is sutured using absorbable running 5-0 monolament sutures,