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Ablation strategies for tumors of the liver and pancreas 269
Figure 18.8 (Continued )
18.6.1 Thermal ablation
Although some groups consider RFA or MWA for unresectable pancreatic tumors, the majority of centers do not
offer thermal ablation because of unacceptable risks in the
setting of low efficacy [48]. Unlike many unresectable
liver tumors, unresectable pancreatic tumors are, by
definition, in close relation to adjacent organs, major
vasculature, or pancreatic ductal tissue. The necessity
270 Chapter 18
Figure 18.8 (Continued )
of 1 cm margins to increase the likelihood of complete
ablation increases the risk of damage to surrounding
viscera and uncontrolled hemorrhage, as well as the
risk of fistula formation and pancreatitis. Although
some have suggested that lower ablation temperatures
may be as efficacious, while limiting morbidity, this has
not been convincingly demonstrated.
18.6.2 Irreversible electroporation
Use of IRE, a nonthermal technique, may allow precise
and complete ablation as a palliative modality for locally
advanced pancreatic tumors (Figure 18.8). Current evidence supports IRE as an approach for the ablation of
large tumors even in close proximity to vascular or ductal
structures [49]. Preclinical animal models have demonstrated rapid resolution of pancreatic inflammation [50].
Furthermore, it is also feasible to treat through blood
vessels or adjacent biliopancreatic ducts. Because the
vessel and duct walls are not compromised by IRE, bleeding and bile leakage are avoided and the apoptosed cells of
the intima/media/adventitia or mucosa/muscularis are
repopulated over time. A recent prospective multicenter
pilot study [7] evaluated palliative IRE in 27 patients with
locally advanced disease, defined as arterial encasement
of the celiac axis or superior mesenteric artery or both.
The authors reported complete ablation in all patients and
no evidence of local recurrence after 90 days. No patients
developed clinical pancreatitis or pancreatic fistulas.
While more evidence is needed, these preliminary data
suggest that IRE may play a role in ablation of locally
advanced disease or in conjunction with pancreatic resection for margin control.
Ablation strategies for tumors of the liver and pancreas 271
KEY POINTS
• Thermal ablation techniques, including RFA, MWA, and cryoablation, use different methods to induce coagulation necrosis.
• RFA is the standard of care for small unresectable HCCs.
• Laparoscopy combines many of the benefits of percutaneous and open ablation approaches.
• Advances in intraoperative ultrasound and ablation probe placement enhance the precision of laparoscopic thermal ablation
and decrease the chances of local recurrence.
• IRE is an emerging nonthermal technique for tumor ablation that spares surrounding vasculature and ductal structures and may
be an option for patients with locally advanced pancreatic cancer.
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CHAPTER 19
Technical considerations for advanced
laparoscopic liver resection
Ho-Seong Han
Department of Surgery, Seoul National University College of Medicine, Gyeonggi-do, Korea
EDITOR COMMENT
In this chapter, expert laparoscopic surgeon Professor Han from Seoul National University provides a comprehensive overview on
technical aspects of laparoscopic liver resection as well as surgical liver anatomy. The chapter highlights the indications and technical
challenges for a Glissonian approach to laparoscopic anatomical liver resectio n with special consideration given to each segment. With
his large experience in performing laparoscopic liver resection for HCC in cirrhotic patients, Professor Han covers key considerations
regarding adequate future liver remnant and limited resections. This chapter will stimulate the appetite of the reader for the video atlas
portion of this book.
Keywords: advanced laparoscopic liver surgery, Glissonian approach, indications and contraindications to advanced laparoscopic liver
surgery, laparoscopic liver surgery in cirrhotic patients
19.1 Introduction
With many reports on encouraging outcomes, laparoscopic liver resection has been accepted as an attractive
alternative to open liver resection. However, there are still
several limitations in the indications of laparoscopic liver
resection that are important to recognize and that we are
in the process of overcoming. First, in most centers,
laparoscopic liver resection has been limited to easily
accessible lesions. Second, a laparoscopic approach has
been considered not well suited when the tumor is close
to a major vascular structure such as the hepatic veins or
inferior vena cava (IVC). Third, this laparoscopic
approach to liver resection still has limited indications
in very large tumors. However, as the experience with
advanced laparoscopic liver surgery grows, its prior and
current indications and contraindications will change
and expand.
Traditionally in Korea and other parts of the world,
indications for laparoscopic liver resection have been
limited to tumors in the peripheral portion of the
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
anterolateral segments of the liver (segments II, III, V,
VI, and the inferior part of IV according to the classification of Couinaud). In contrast, lesions in the posterior or
superior part of the liver (segments I, VII, VIII, and the
superior part of IV) are considered poor indications for
laparoscopic liver resection. However, over time, flexible
laparoscopic cameras, high-definition imaging, and various advanced energy devices for parenchymal transection have been introduced for clinical use. These technical
advances help overcome inadequate exposure with a
greater diffusion of advanced laparoscopic liver surgery
throughout Korea, Asia, and the rest of the world. Intraoperative ultrasonography is routinely used to locate
lesions and guide the resection plane even for deeply
located and invisible lesions.
When the tumor is centrally located (close to major
hepatic veins or the IVC), laparoscopic liver resection has
been considered a contraindication because of the risk of
major hemorrhage and concerns for adequately controlling bleeding. While these concerns are valid, recent
developments in instrumentation for parenchymal
273
274 Chapter 19
dissection have made laparoscopic liver resection safer
and more refined than before. These instruments include
the laparoscopic Cavitron ultrasonic surgical aspirator
(CUSA; Valleylab, Inc., Boulder, Colorado) which, similar
to open liver surgery, allows safe liver resection close to
the portal pedicle, major hepatic veins, or IVC. As for the
current limitations on tumor size, these may change as a
result of growing experience with advanced laparoscopic
liver resection and the ongoing development of laparoscopic devices. However, the incision required to remove
large tumors and prevention of tumor spillage through
rupture will remain key considerations for laparoscopic
liver surgeons.
The type of resection may also depend on the remaining liver’s functional capacity. Patients with hepatocellular carcinoma (HCC) usually have poor liver
function as a result of chronic liver disease or liver cirrhosis. Therefore, it is recommended to spare as much future
liver remnant as possible without jeopardizing oncological safety. Anatomical liver resection may be advantageous in preserving the future liver remnant while also
achieving long-term control of the cancer in some cases.
Several approaches for anatomical liver resection are
available today. The Glissonian pedicle approach is one of
the most important concepts for anatomical liver resection. Here, we describe technical points for performing
advanced anatomical laparoscopic liver resection.
19.2 General considerations
The indications for laparoscopic liver resection are similar
to open liver resection in terms of the preoperative assessment of liver function, type of liver resection, and postoperative care. For patients with HCC, absence of severe
portal hypertension and adequate hepatic reserve are
prerequisites for surgery. For metastatic liver tumors
from colorectal cancer, liver resection is indicated in
most cases when there is no evidence of extrahepatic
disease and all known disease can be resected. A simultaneous laparoscopic liver resection of metastatic disease
and minimally invasive colorectal resection can achieve
potential cure with minimal morbidity.
Deeply seated tumors located more than 3 cm from the
liver surface are usually best resected with anatomical
liver resection rather than nonanatomical tumorectomy.
Up to 3 cm from the liver surface, major hepatic vein
branches and the hepatic veins themselves are rarely
encountered. Especially in Asia, it is thought that complete tumor clearance (especially HCC) and a safe tumor
margin can be best achieved with an anatomical resection, described below.
19.3 Operative technique
Patient positioning, trocar placement, and the type of
resection should be decided prior to surgery according
to tumor location and surgical approach. It is our technique to establish pneumoperitoneum through a 10 mm
umbilical port and maintain abdominal pressure below
12 mmHg to reduce the potential risk of CO
Other advanced laparoscopic liver surgeons have experimented with raising the abdominal pressure above
15 mmHg and even higher to achieve a “Pringle” effect
with the aid of the pneumoperitoneum. An infraumbilical
access is used in cirrhotic patients to avoid injury to a
recannulated umbilical vein. A 30° laparoscope or flexible
laparoscope is employed. Laparoscopic ultrasonography
is used for precise localization of the tumor, for demonstrating a satellite nodule of HCC, and for achieving an
adequate tumor-free margin.
For the superficial hepatic parenchymal transection,
we use energy devices such as the Harmonic Scalpel
(Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) or a SonoSurg (Olympus Inc., Japan), and for the deeper portion of
the parenchyma, laparoscopic CUSA. Once the specimen
has been completely detached from the rest of the liver, it
is inserted into a protective vinyl endoscopic retrieval bag.
We usually extract small specimens by extending the
epigastric or umbilical port site, especially for limited
resections such as tumorectomy specimens. Especially
large hemihepatectomy specimens in younger patients
are removed through a suprapubic transverse incision. At
our institution, we apply a fibrin glue sealant (Greenplast,
Green Cross Corporation, Seoul, Korea) to the raw surface after hemostasis has been achieved. After irrigating
the surgical field, a silastic drain is inserted in some cases
and the wound is closed in layers.
19.3.1 Glissonian approach
The Glissonian sheath is a fibrous envelope encircling the
portal triad from the hepatoduodenal ligament to its
segmental pedicles in the liver. By controlling the Glissonian pedicle, a precise anatomical liver resection can be
performed. The Glissonian approach is an important
embolism.
2
Technical considerations for advanced laparoscopic liver resection 275
strategy for both minor and major anatomical liver resection through controlling inflow to the liver area to be
resected. This approach was first described by Takasaki in
1998 for open liver surgery and in 2005, we applied such a
Glissonian approach to a laparoscopic anatomical resection of the right posterior section.
19.3.2 Operative technique for major
liver resection
Typically, for a right hemihepatectomy or right posterior
sectionectomy, the liver is fully mobilized off the IVC and
multiple small hepatic veins are clipped and divided. The
portal pedicles are dissected outside the liver parenchyma
for individual ligation. In our approach, following isolation of the Glissonian pedicle, the portal, arterial, and
bile duct pedicles are controlled separately. After opening
the Glissonian sheath, the arterial and portal branches can
be clipped and divided. When the portal branch is too
large to apply clips, it is divided with a linear stapler.
When the Glissonian approach is applied to right-sided
resection, the hilar dissection is performed first to isolate
the right Glissonian pedicles at the inferior surface of the
quadrate lobe (area of the liver between the gallbladder
fossa and the umbilical vein behind the porta hepatis).
When performing a right posterior sectionectomy, the
right Glissonian pedicle is followed to its division into
the anterior and posterior Glissonian pedicles. Each of
these two pedicles is isolated and then the posterior
Glissonian pedicle is divided using a linear stapler.
19.3.3 Laparoscopic segmental
liver resection
19.3.3.1 Segment I (see Video 4)
Resection of the caudate lobe is one of the most challenging procedures in liver surgery, both open and laparoscopic, because of its deep location and position close to
the IVC. Although a true anatomical caudate lobectomy is
a challenging technical procedure, a laparoscopic nonanatomical and even anatomical segmentectomy I is
feasible in selected patients. Tumor location in the Spiegelian lobe facilitates a laparoscopic approach.
For caudate resection, the patient is placed in the 30°
reverse Trendelenburg position with the lower limbs
apart. The operator stands between the legs of the patient.
The procedure begins with mobilization of the left liver.
Then the caudate lobe is retracted anteriorly off the IVC.
Next, small hepatic veins off the caudate lobe to the IVC
are isolated and divided. After completely mobilizing the
caudate lobe, the parenchymal transection is performed
while maintaining medial traction of the caudate lobe.
The small, vascular or biliary tributaries to the caudate
lobe of the main left and right portal pedicle are isolated,
clipped, and divided.
19.3.3.2 Segments II and III (see Videos 2 and 3)
At most centers, a laparoscopic approach to left lateral
sectionectomy is usually the first attempt at performing
an anatomical liver resection.
The operative procedure is performed with the patient
placed in a supine position and 30° reverse Trendelenburg. The operator stands at the right side of the patient.
The vascular and biliary structures can be controlled
before or during parenchymal transection. With lateral
traction of the divided round ligament, parenchymal
transection just left of the falciform ligament is performed
cephalad using an energy device. Other groups leave the
round and falciform ligaments intact for countertraction
without the need to use an instrument. The Glissonian
pedicles to segments II and III can be isolated separately by
an extrahepatic or intrahepatic approach. For intraparenchymal control of the pedicles to segments II and III, a
small portion of the parenchymal transe ction is begun.
Once the main left portal pedicle is approached, the
Glisson’s pedicles to the left lateral section can be controlled using a linear stapler. An additional firing of the
stapler is used for division of the left hepatic vein. By
isolating Glissonian pedicles of segments II or III, an
anatomical segmentectomy of segment II or segment III
is possible.
19.3.3.3 Segment IV (see Videos 5, 6, and 7)
Tumorectomy is a feasible and safe resection for a relatively small tumor located in the superficial and inferior
part of segment IV. However, when a tumor is located in
the superior part or is deeply buried in the liver parenchyma, left hemihepatectomy is the preferred approach.
Tumorectomy of a small tumor located in the superior
part of segment IV is feasible but significantly more
challenging, because the transection line may encounter
two main hepatic veins.
Anatomical segmentectomy IV is also feasible,
although this procedure is technically demanding. The
Glissonian pedicle, which usually consists of several
branches, needs to be isolated and controlled. Typically
a segmentectomy IV is begun at the medial side of segment IV just medial to the falciform ligament. As the
276 Chapter 19
dissection is deepened towards the left Glissonian pedicle,
the Glissonian branches to segment IV can be identified.
Then, after temporary clamping of Glissonian branches to
segment IV, the ischemic demarcation delineates the
borders between the left lateral and right anterior section.
19.3.3.4 Segments V and VI (see Videos 8, 9, 13,
and 16)
Segments V and VI are easily accessible for laparoscopic
liver resection. Cholecystectomy and full liver mobilization are usually not necessary for tumorectomy or segmentectomy for a small superficial tumor. However, a
deeply located or large tumor in segment VI requires right
posterior sectionectomy or right hemihepatectomy,
depending on the specific location or the distance of
the tumor from the right hepatic vein. For a deep or large
tumor in segment V, right hemihepatectomy will be the
resection of choice, although right anterior sectionectomy
can be considered in experienced hands. However, anatomical right anterior or posterior sectionectomy should
only be attempted if the patient has an adequate future
liver remnant in case conversion to a right hepatectomy is
necessary. Anatomical V and VI bisegmentectomy is
also feasible.
For anatomical resection of segment V, the Glissonian
branch to segment V is isolated. First, the right anterior
branch of the Glissonian pedicle is isolated, and then the
branch to segment V is further dissected and isolated.
Typically, segment V has more than one Glissonian pedicle. With clamping of the isolated branches, demarcation
of segment V is achieved. Following the demarcation line,
anatomical segment V segmentectomy can be performed.
Anatomical segment VI segmentectomy starts with
isolation of the Glissonian branch or branches to segment
VI. After careful dissection of the right posterior Glissonian pedicle, the surgeons progress peripherally to reach
the branch to segment VI which can then be isolated. By
clamping the Glissonian pedicle to segment VI, an anatomical segment VI segmentectomy can be performed.
19.3.3.5 Segments VII and VIII (see Videos 10, 11,
13, and 16)
Segments VII and VIII are difficult locations to access via
laparoscopy because of the limited visualization that can
be achieved via a purely transabdominal laparoscopic
approach. It is also difficult to control bleeding should
it occur. Therefore, for safe resection of tumors in this
location, a flexible laparoscope can help overcome the
limited visualization. Alternatively, or in addition, a
transthoracic approach can be performed as published
by the editors. A laparoscopic CUSA can be very useful for
meticulous parenchymal transection to reduce bleeding
from major vessels. It is critical that the main working port
is placed as close as possible to the costal margin to
minimize the distance between port and target. For tall
or obese patients, even with the ports placed close to the
costal margin, instruments cannot reach the dome of the
liver, in which case, an extra-long or thoracoscopic
approach may be required.
Poor visualization of the operative field at the dome and
the intricate transection needed to create a curved or
angulated transection line can make deeper lesions at the
dome particularly difficult to resect. Caudal traction of the
liver after releasing the right triangular ligament may
facilitate exposure and transection. For those lesions,
ultrasound-guided outlining of the transection line may
be needed as a Glissonian approach can be challenging. At
our institution, we consider even limited liver resections
in segment VII or VIII as difficult and major resections.
Vascular control techniques such as Pringle’s maneuver
may reduce blood loss during tumorectomy.
For deep-seated large tumors in segment VII, a right
posterior sectionectomy can be preferable over a complicated isolated anatomical resection of segment VII or right
hepatectomy.
Compared with a right hepatectomy for segment VII
lesions, a posterior sectionectomy preserves the liver
volume of the anterior section. Nevertheless, a posterior
sectionectomy may be technically very demanding. The
main problem during a right posterior sectionectomy is
the difficulty of performing the parenchymal transection.
Injury of major branches of the right hepatic vein or the
right hepatic vein itself can lead to massive bleeding that
can be very difficult to control laparoscopically.
For a deep-seated large tumor in segment VIII, a right
hepatectomy can be chosen for anatomical liver resection.
This is only possible, of course, if the future liver remnant
has been calculated to be adequate. However, for severely
cirrhotic patients with an insufficient hepatic reserve, a
limited resection may be the best approach for tumors
located in segment VII or VIII.
When the lesion encompasses segment VIII or IV, the
challenging central bisectionectomy can be performed.
The Glissonian pedicle to segment IV and the right anterior Glissonian pedicle are isolated to confirm the area of
segment IV and right anterior section. After the ischemic
Technical considerations for advanced laparoscopic liver resection 277
demarcation line is drawn, the parenchymal transaction
is performed in the usual manner.
laparoscopic liver resection regarding tumor location are
gradually being overcome. In the near future, tumor
location per se might no longer be a contraindication
for a laparoscopic liver resection. However, to achieve
19.4 Conclusion
safe laparoscopic liver resection, each surgical technique
must be individualized according to patient factors,
With the improvement of laparoscopic techniques and
the development of new technologies, the limitations of
KEY POINTS
• General considerations regarding the safety of patients undergoing laparoscopic liver resections, such as adequate future liver
remnant, apply to a laparoscopic approach.
• Anatomical liver resections via the Glissonian approach require optimal technology and surgical technique to perform safely.
• Left lateral sectionectomy might be the optimal procedure to gain experience with anatomical laparoscopic liver resection.
• The overview on anatomical segmental resection given in this chapter will enhance the understanding of the video atlas portion
of this book.
Videos 1–19 will be of interest to readers of this chapter.
Visit the companion website at:
future liver remnant, and tumor location with its relationship to major hepatic vessels.
www.wiley.com\go\conrad\liver-pancreas-biliary-laparoscopic-surgery
CHAPTER 20
Laparoscopic left lateral sectionectomy and
left hepatectomy for living donation
Claire Goumard and Olivier Scatton
Department of Hepatobiliary Surgery and Liver Transplantation, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
EDITOR COMMENT
In this chapter, the authors share their experience with laparoscopic living donor liver transplantation. The key message of the chapter is
that every measure should be taken to ensure donor safety during laparoscopic graft harvest. With one of the largest experiences in living
donor liver transplantation, the authors share key steps and technical tricks to ensure donor safety, successfully complete the procedure
laparoscopically, and optimize graft function. These include an extensive work-up of the donor’s health and liver function, assessment of
anatomical variations, a two-surgeon technique with alternation between the two experienced transplant surgeons, predefined criteria
for conversion, and checklisting of key operative steps. The authors further share tips to minimize warm ischemia time during
laparoscopic graft removal. While in this chapter and the excellent educational accompanying video, left lateral and left donor
hepatectomy are described, the future of laparoscopic living donor graft harvest might include laparoscopic left hepatectomy including
the middle hepatic vein and laparoscopic right hepatectomy.
Keywords: future procedures in living donor liver transplantation, laparoscopic living donor liver transplantation, left hepatectomy
for living donation, left lateral sectionectomy for living donation
20.1 Introduction
Living donor liver transplantation has become a widely
accepted alternative to cadaveric transplantation [1,2].
Such living donor grafts provide similar or better shortterm graft function and long-term survival rates when
compared with cadaveric liver grafts, especially in children [3–5]. Living donation has the advantages of shortening waiting list times and minimizing cold ischemia
time. While significant benefits for the recipients exist, the
surgical risk for donors remains the main limiting factor
for a wider application of living donation [5].
Limited resection tries to reduce the risk to the donor.
Therefore, open left lateral sectionectomy is a wellaccepted and standardized procedure, associated with
low rates of complications and mortality in living donor
transplantation [6–9].
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
278
A laparoscopic approach was first proposed in 2002
with the premise of optimizing donor safety [6]; a comparative study demonstrated its safety and reproducibility
in 2006 [7]. The reason why laparoscopic resection was
propagated was the major advantages for the donor, that
included reduced postoperative pain and shortened hospital stay [9,10]. In general, the left liver is more favorable
for laparoscopic procurement than the right liver: there
are fewer vascular and biliary anatomical variations,
there is adequate length of extrahepatic vessels that
allows easy control, and its anterior position gives access
with minimal mobilization. Further, modern imaging
allows an accurate and reliable assessment of both vascular and biliary anatomy. With growing experience and
technical innovations, left living donor liver transplantation has evolved from an innovative procedure initially
described in 2002 to the standardized procedure we
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