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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1260_Библиотеки_им_академика_М_И_Перельмана
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Left lateral sectionectomy 359
Figure v2.7 Cranial to caudal view. Notice again the closeness of P3 and P2, which are usually controlled with a stapler.
Figure v2.8 Operative view. Here we can see again how the P2 and P3 pedicles curve back anteriorly towards the operative surgeon.
Injury to the main LPP needs to be avoided when opening the umbilical fissure.
VIDEO 3
Left lateral sectionectomy using a laparoscopic
single access device
Video duration 6 minutes 49 seconds
In this video, we will show a left lateral sectionectomy
using a laparoscopic single access device.
OUTLINE
The video will cover
• Port positioning
• Parenchymal transection
• Suturing
• Important points.
It is very important to determine the positioning of the
single access device on preoperative imaging before the
case. Owing to the lack of triangulation, inline working
along the axis of parenchymal transection is very important (Figure v3.1). We begin the case with intraoperative
ultrasound. The relationship between the lesion and the
vascular structures is determined and lesions in the future
liver remnant are excluded. Using an endoclosure device,
we place a suture around the ligamentum teres. This can
be used to retract the liver superiorly. Next, we open up
the parenchyma to expose the portal pedicle to segment
III. For this, we divide the bridge between segments III
and IVb. This uncovers the umbilical fissure bearing the
portal pedicle to segment III. Next, we open up the
Figure v3.1 Determine the positioning of the single access device on preoperative imaging before the case.
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.
360
Left lateral sectionectomy using a laparoscopic single access device 361
parenchyma along the falciform ligament. Then we determine the relationship between portal pedicle segment II
and the lesion.
We are now ready to staple divide the portal pedicle to
segment III. Because of the size of the stapler handle, it is
difficult for the assistant to help at this step. Nevertheless, we
always try to bring in a vascular clamp along the axis of the
stapler in case of stapler misfiring. We can now continue the
parenchymal division along the falciform ligament. With an
additional staple firing, we open up the parenchyma. At this
point, we are ready to staple divide the portal pedicle to
segment II. We are now uncovering the intraparenchymal
portion of the left hepatic vein. The left hepatic vein is now
staple divided as well. Despite the limitation of working with
asingleaccessdevice,itisveryimportanttobringina
vascular clamp at this step. In case of stapler misfiring, having
a vascular clamp ready is crucial. With division of the left
triangular ligament, the specimen is completely detached.
At the end of the case, we notice a minor bile leak from
the portal pedicle to segment III. We will suture this bile
Anatomy figures
leak closed. Suturing while using a single access device
can be very difficult owing to the lack of triangulation.
Therefore, we are using an automated needle driver that
can be angled along the axis. You can see here oversewing
of the staple line. The picture in the top right-hand corner
shows the outside view. Rotation of the needle driver is
activated with the thumb. The further away the suture
target is, the more difficult it gets. A clip at the end of the
suture can provide additional security.
IMPORTANT POINTS
• Safety first – the use of the single access device should not
compromise the safety of the surgery in any way.
• The single access device should be placed in line with the
parenchymal transection line. This should be determined
from preoperative imaging.
• Articulating instruments can facilitate the surgery, for
example the suturing process.
• New devices will make this surgery easier and safer in the
future.
Figure v3.2 Relevant anatomy for laparoscopic left lateral sectionectomy. The operation begins with opening the umbilical fissure.
The key is to avoid injury to the main LPP or the P4b pedicle. The MHV can be surprisingly close to the falciform ligament.
Undercutting the falciform ligament should be avoided. Care must be taken during dissection of the drainage of the LHV into the
IVC. An MHV injury at a common drainage with the MHV can lead to significant injury.
362 Video 3
Figure v3.3 Initial view for laparoscopic left lateral sectionectomy. After opening the umbilical fissure, the PP to segment III and,
shortly thereafter, the pedicle to segment III are controlled. Notice the closeness of these two pedicles (P3 and P2).
Figure v3.4 Cranial to caudal view. Notice again the closeness of P3 and P2, which are usually controlled with a stapler.
Left lateral sectionectomy using a laparoscopic single access device 363
Figure v3.5 Operative view. Here we can see again how the P2 and P3 pedicles curve back anteriorly towards the operative surgeon.
Injury to the main LPP needs to be avoided when opening the umbilical fissure.
VIDEO 4
Segmentectomy I with resection of
inferior vena cava
Video duration 19 minutes 21 seconds
In this video, we show you a caudate lobectomy with
resection of the inferior vena cava (IVC).
OUTLINE
The video has the following outline:
• Port positioning
• Ultrasound
• Liver mobilization
• Dissection of the hepatocaval space
• Parenchymal transection
• Partial resection of the IVC
• Important points.
The port positioning is similar to a left hepatectomy
(Figure v4.1). The ports at the costal margin are used for
retraction and the vascular clamp.
The first step is the intraoperative ultrasound. On this
ultrasoundimage, the tumorinvading the IVC can beseen.
We are also looking out for the caudate veins which
will be controlled during the parenchymal transection
(Figure v4.2).
Good spatial understanding of the tumor relationship
to the liver and IVC is crucial for this case (Figure v4.3).
After the intraoperative ultrasound, we mobilize the liver.
This is the view with superior traction of the left lateral
segment. Next, we open up the hepatocaval ligament.
Figure v4.1 The set-up is similar to a left hepatectomy with the ports placed slightly further to the patient’s left. The ports at the
costal margin are used for retraction and the vascular clamp.
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.
364
Segmentectomy I with resection of inferior vena cava 365
Figure v4.2 The caudate veins will be controlled during the parenchymal transection.
Figure v4.3 Good spatial understanding of the relationship of the tumor to the liver and IVC is crucial for this case. On ultrasound,
the close relationship between tumor and IVC is determined.
366 Video 4
Figure v4.4 The hepatocaval space is dissected out and a nasogastric tube (NGT) fed into this space ventral to the IVC. It is identified
on ultrasound.
Here, we are following the ligament of Arantius in the
cephalad direction. Of note, this patient has a replaced left
hepatic artery which we need to preserve for this case.
Here, we are opening up the ligament of Arantius further.
Wide mobilization is necessary for this case. Here, we are
dissecting the intrahepatic IVC.
Now we are continuing our dissection at the epiploic
foramen. Porta and duodenum are retracted with the
suction. Short hepatic veins are controlled with clips.
Here, we are continuing our dissection along the hepatocaval ligament. Here, we are beginning the dissection of
the hepatocaval space. Complete mobilization of the liver
on the right side is crucial, and here we are dissecting
the right triangular ligament. We are also dissecting the
hepatocaval ligament on the right side. For later dissection of the hepatocaval space, we are also taking
down the falciform as well as the coronary ligament.
Here, the suprahepatic IVC comes into view. At this point,
the landing zone of the dissection of the hepatocaval space
has been completely dissected out.
Next, we would like to show you the dissection of the
hepatocaval space. The nasogastric tube (NGT) can be
useful in this dissection. It is crucial to be very gentle at
this step to avoid injury to the IVC. After the outlet of
the hepatocaval space has been dissected, we begin the
dissection of the inlet. We are very gentle at this step to
avoid any injury. Using ultrasound, we control the path
of the nasogastric tube through the hepatocaval space.
Here, the air artifacts of the nasogastric space can be seen
next to the lesion.
The next step is the parenchymal transection
(Figure v4.4). The liver is retracted superiorly. We are
beginning the parenchymal transection and identifying
caudate veins. After opening the parenchyma a little bit,
we are opening out one of the caudate veins. The caudate
vein is cut and divided. Additional caudate veins are
dissected out. They are also controlled with clips and
divided. Here, another caudate lobe branch is dissected
out; it will be clipped and divided. Now the superior
portion of the caudate lobe is completely dissected out.
Here at the dissection of the superior part of the caudate
lobe, we are controlling a caudate vein. At this step, we are
deepening the transection along the paracaval portion of
the caudate lobe. Here, an additional caudate vein is
identified and it will be dissected out, clipped, and divided.
In this image, we can see the lesion inferiorly. We are
deepening our transection line down to the IVC.
We are reaching a point at our dissection where the
caudate lobe has been entirely freed and only the lesion
is adherent to the IVC. Here, we are ensuring the
Segmentectomy I with resection of inferior vena cava 367
hepatocaval space has been completely dissected out.
Here, we are dissecting between the left and middle
hepatic veins. In order to ensure a bloodless field, a
hemostatic agent is placed in that space.
The last step of the operation isthe partial IVC resection.
The caudate lobe has been entirely freed, and it is only
adherent to the IVC at the level of the metastasis. We are
ensuring good mobility of the IVC for the later
reconstruction. In order to ensure enough mobility after
clamping for the partial resection of the IVC, we are
dissecting some of the hepatocaval ligament fibers.
Now we are placing a vascular clamp along the IVC where
a metastasis is invading it. Here, the clamped part of the
IVC is dissected off. At this step, the specimen is completely detached. We are placing the specimen in an
endoscopic retrieval bag. We are proceeding to suture
Anatomy figures
close the IVC. We are now ready to slowly open the
vascular clamp. Finally, we confirm that we have excellent hemostasis.
IMPORTANT POINTS
• Caudate lobe resection requires an optimal liver
mobilization.
• The laparoscopic view along the IVC facilitates the
dissection.
• Avoid bleeding during dissectionof the hepatocaval space
in order to maintain excellent working conditions.
• Be aware of caudate veins.
• A laparoscopic IVC resection is a very challenging case. In
addition to laparoscopic skills, it requires careful preparation to manage significant blood loss.
Figure v4.5 Critical anatomy of the caudate lobe. The caudate lobe extends between the IVC and PP up to the hepatic venous
confluence. Venous drainage is from direct branches from IVC. Direct branches from left and RPP supply segment I.
368 Video 4
Figure v4.6 Relationship of portal structures to segment I. The direct branches from the left and right portal pedicles can cause
significant bleeding. They are relevant not only when performing a caudate lobectomy but also when dissecting out the main PP for
other types of liver resection.
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