Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1310_Библиотеки_им_академика_М_И_Перельмана.pdf
8 Minimally Invasive Resection of Colorectal Liver Metastases 105
Conclusion
In conclusion, the literature demonstrates that in properly selected patients, minimally invasive liver resection is a feasible and safe option, best performed by
surgeons trained in open liver surgery who are skilled in minimally invasive
techniques. Available data suggest that open, laparoscopic, and robotic approaches
have similar perioperative outcomes. Short- and long-term oncologic outcomes
appear to be equivalent. Currently, the majority of minimally invasive hepatectomies are nonanatomic resections, and therefore there is no clear-cut advantage to
the robotic approach over laparoscopy in minor hepatectomy. There exists no
high-quality, prospective data analyzing minimally invasive hepatectomy. Therefore, it is difficult to draw any definitive conclusions at this time with regard to
overall efficacy and benefits in both immediate (length of stay, postoperative pain,
morbidity, mortality, and cost-effectiveness) and long-term (quality of life, oncologic recurrence) patient outcomes. Existing data are promising and warrant further
investigation.
References
1. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin. 2016;66(1):7–30.
doi:10.3322/caac.21332.
2. Yoo PS, Lopez-Soler RI, Longo WE, Cha CH. Liver resection for metastatic colorectal cancer
in the age of neoadjuvant chemotherapy and bevacizumab. Clin Colorectal Cancer. 2006;6
(3):202–7. doi:10.3816/CCC.2006.n.036.
3. Alberts SR, Horvath WL, Sternfeld WC, Goldberg RM, Mahoney MR, Dakhil SR, et al.
Oxaliplatin, fluorouracil, and leucovorin for patients with unresectable liver-only metastases
from colorectal cancer: a North Central Cancer Treatment Group phase II study. J Clin Oncol.
2005;23(36):9243–9. doi:10.1200/JCO.2005.07.740.
4. Muratore A, Zorzi D, Bouzari H, Amisano M, Massucco P, Sperti E, et al. Asymptomatic
colorectal cancer with un-resectable liver metastases: immediate colorectal resection or
up-front systemic chemotherapy? Ann Surg Oncol. 2007;14(2):766–70. doi:10.1245/s10434-
006-9146-1.
5. Hayashi M, Inoue Y, Komeda K, Shimizu T, Asakuma M, Hirokawa F, et al. Clinicopathological analysis of recurrence patterns and prognostic factors for survival after hepatectomy
for colorectal liver metastasis. BMC Surg. 2010;27(10):27. doi:10.1186/1471-2482-10-27.
6. Kelly ME, Spolverato G, Le GN, Mavros MN, Doyle F, Pawlik TM, et al. Synchronous
colorectal liver metastasis: a network meta-analysis review comparing classical, combined,
and liver-first surgical strategies. J Surg Oncol. 2015;111(3):341–51. doi:10.1002/jso.23819.
7. Leporrier J, Maurel J, Chiche L, Bara S, Segol P, Launoy G. A population-based study of the
incidence, management and prognosis of hepatic metastases from colorectal cancer. Br J Surg.
2006;93(4):465–74. doi:10.1002/bjs.5278.
8. Manfredi S, Lepage C, Hatem C, Coatmeur O, Faivre J, Bouvier AM. Epidemiology and
management of liver metastases from colorectal cancer. Ann Surg. 2006;244(2):254–9.
doi:10.1097/01.sla.0000217629.94941.cf.
9. Bird NC, Mangnall D, Majeed AW. Biology of colorectal liver metastases: a review. J Surg
Oncol. 2006;94(1):68–80. doi:10.1002/jso.20558.
10. de Jong MC, Pulitano C, Ribero D, Strub J, Mentha G, Schulick RD, et al. Rates and patterns
of recurrence following curative intent surgery for colorectal liver metastasis: an international
106 L.M. Ocuin and A. Tsung
multi-institutional analysis of 1669 patients. Ann Surg. 2009;250(3):440–8. doi:10.1097/
SLA.0b013e3181b4539b.
11. Cunningham JD, Fong Y, Shriver C, Melendez J, Marx WL, Blumgart LH. One hundred
consecutive hepatic resections. Blood loss, transfusion, and operative technique. Arch Surg.
1994;29(10):1050–6.
12. Lin NC, Nitta H, Wakabayashi G. Laparoscopic major hepatectomy: a systematic literature
review and comparison of 3 techniques. Ann Surg. 2013;257(2):205–13. doi:10.1097/SLA.
0b013e31827da7fe.
13. Karoui M, Penna C, Amin-Hashem M, Mitry E, Benoist S, Franc B, et al. Influence of
preoperative chemotherapy on the risk of major hepatectomy for colorectal liver metastases.
Ann Surg. 2006;243(1):1–7.
14. Poultsides GA, Servais EL, Saltz LB, Patil S, Kemeny NE, Guillem JG, et al. Outcome of
primary tumor in patients with synchronous stage IV colorectal cancer receiving combination
chemotherapy without surgery as initial treatment. J Clin Oncol. 2009;27(20):3379–84.
doi:10.1200/JCO.2008.20.9817.
15. Siriwardena AK, Mason JM, Mullamitha S, Hancock HC, Jegatheeswaran S. Management of
colorectal cancer presenting with synchronous liver metastases. Nat Rev Clin Oncol. 2014;11
(8):446–59. doi:10.1038/nrclinonc.2014.90.
16. Ocuin LM, Tsung A. Minimally invasive hepatic surgery. Surg Clin North Am. 96(2): 299–
313. doi:10.1016/j.suc.2015.12.004.
17. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically
assisted and open colectomy for colon cancer. N Engl J Med. 2004;350(20):2050–9. doi:10.
1056/NEJMoa032651.
18. Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AM, et al. Short-term endpoints
of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC
CLASICC trial): multicentre, randomised controlled trial. Lancet. 2005;365(9472):1718–26.
doi:10.1016/S0140-6736(05)66545-2.
19. Ghezzi F, Cromi A, Ditto A, Vizza E, Malzoni M, Raspagliesi F, et al. Laparoscopic versus
open radical hysterectomy for stage IB2-IIB cervical cancer in the setting of neoadjuvant
chemotherapy: a multi-institutional cohort study. Ann Surg Oncol. 2013;20(6):2013;2007–15.
doi:10.1245/s10434-012-2777-5.
20. Trabulsi EJ, Hassen WA, Touijer AK, Saranchuk JW, Guillonneau B. Laparoscopic radical
prostatectomy: a review of techniques and results worldwide. Minerva Urol Nefrol. 2003;55
(4):239–50.
21. Luketich JD, Pennathur A, Awais O, Levy RM, Keeley S, Shende M, et al. Outcomes after
minimally invasive esophagectomy: review of over 1000 patients. Ann Surg. 2012;256(1):95–
103. doi:10.1097/SLA.0b013e3182590603.
22. Martel G, Boushey RP. Laparoscopic colon surgery: past, present and future. Surg Clin N
Am. 2006;86(4):867–97. doi:10.1016/j.suc.2006.05.006.
23. Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection—2,804
patients. Ann Surg. 2009;250(5):831–41. doi:10.1097/SLA.0b013e3181b0c4df.
24. Jayne DG, Guillou PJ, Thorpe H, Quirke P, Copeland J, Smith AM, et al. Randomized trial of
laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC
CLASICC Trial Group. J Clin Oncol. 2007;25(21):3061–8. doi:10.1200/JCO.2006.09.7758.
25. Berguer R, Rab GT, Abu-Ghaida H, Alarcon A, Chung J. A comparison of surgeons’ posture
during laparoscopic and open surgical procedures. Surg Endosc. 1997;11(2):139–42.
26. Cadiere GB, Himpens J, Germay O, Izizaw R, Degueldre M, Vandromme J, et al. Feasibility
of robotic laparoscopic surgery: 146 cases. World J Surg. 2001;25(11):1467–77.
27. 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. doi:10.1097/SLA.
0000000000001180.
8 Minimally Invasive Resection of Colorectal Liver Metastases 107
28. Croome KP, Farnell MB, Que FG, Reid-Lombardo K, Truty MJ, Nagorney D, et al.
Pancreaticoduodenectomy with major vascular resection: a comparison of laparoscopic versus
open approaches. J Gastrointest Surg. 2015;19(1):189–94. doi:10.1007/s11605-014-2644-8.
29. Croome KP, Farnell MB, Que FG, Reid-Lombardo KM, Truty MJ, Nagorney DM, et al. Total
laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic
advantages over open approaches? Ann Surg. 2014;260(4):633–8; discussion 638–40. doi:10.
1097/SLA.0000000000000937.
30. Kendrick ML. Laparoscopic and robotic resection for pancreatic cancer. Cancer J. 2012;18
(6):571–6. doi:10.1097/PPO.0b013e31827b8f86 .
31. Kendrick ML, Cusati D. Total laparoscopic pancreaticoduodenectomy: feasibility and
outcome in an early experience. Arch Surg. 2010;145(1):19–23. doi:10.1001/archsurg.2009.
243.
32. Kendrick ML, Sclabas GM. Major venous resection during total laparoscopic pancreaticoduodenectomy. HPB. 2011;13(7):454–8. doi:10.1111/j.1477-2574.2011.00323.x.
33. Nguyen KT, Marsh JW, Tsung A, Steel JJ, Gamblin TC, Geller DA. Comparative benefits of
laparoscopic vs open hepatic resection: a critical appraisal. Arch Surg. 2011;146(3):348–56.
doi:10.1001/archsurg.2010.248.
34. Tsung A, Geller DA, Sukato DC, Sabbaghian S, Tohme S, Steel J, et al. Robotic versus
laparoscopic hepatectomy: a matched comparison. Ann Surg. 2014;259(3):549–55. doi:10.
1097/SLA.0000000000000250.
35. Zeh HJ 3rd, Bartlett DL, Moser AJ. Robotic-assisted major pancreatic resection. Adv Surg.
2011;45:323–40.
36. Zureikat AH, Moser AJ, Boone BA, Bartlett DL, Zenati M, Zeh HJ 3rd. 250 robotic
pancreatic resections: safety and feasibility. Ann Surg. 2013;258(4):554–9; discussion 559–
62. doi:10.1097/SLA.0b013e3182a4e87c.
37. Zureikat AH, Nguyen KT, Bartlett DL, Zeh HJ, Moser AJ. Robotic-assisted major pancreatic
resection and reconstruction. Arch Surg. 2011;146(3):256–61. doi:10.1001/archsurg.2010.
246.
38. Buell JF, Cherqui D, Geller DA, O’Rourke N, Iannitti D, Dagher I, et al. The international
position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg. 2009;250
(5):825–30.
39. Cai XJ, Yang J, Yu H, Liang X, Wang YF, Zhu ZY, et al. Clinical study of laparoscopic
versus open hepatectomy for malignant liver tumors. Surg Endosc. 2008;22(11):235 0–6.
doi:10.1007/s00464-008-9789-z.
40. Mirnezami R, Mirnezami AH, Chandrakumaran K, Abu Hilal M, Pearce NW, Primrose JN, et al.
Short- and long-term outcomes after laparoscopic and open hepatic resection: systematic review
and meta-analysis. HPB. 2011;13(5):295–308. doi:10.1111/j.1477-2574.2011.00295.x.
41. Amodeo A, Linares Quevedo A, Joseph JV, Belgrano E, Patel HR. Robotic laparoscopic
surgery: cost and training. Minerva Urol Nefrol. 2009;61(2):121–8.
42. Giulianotti PC, Coratti A, Angelini M, Sbrana F, Cecconi S, Balestracci T, et al. Robotics in
general surgery: personal experience in a large community hospital. Arch Surg. 2003;138
(7):777–84. doi:10.1001/archsurg.138.7.777.
43. Coelho RF, Rocco B, Patel MB, Orvieto MA, Chauhan S, Ficarra V, et al. Retropubic,
laparoscopic, and robot-assisted radical prostatectomy: a critical review of outcomes reported
by high-volume centers. J Endourol. 2010;24(12):2003–15. doi:10.1089/end.2010.0295.
44. O’Neill M, Moran PS, Teljeur C, O’Sullivan OE, O’Reilly BA, Hewitt M, et al.
Robot-assisted hysterectomy compared to open and laparoscopic approaches: systematic
review and meta-analysis. Arch Gynecol Obstet. 2013;287(5):907–18. doi:10.1007/s00404-
012-2681-z.
45. Tatooles AJ, Pappas PS. Gordon PJ, Slaughter MS. Minimally invasive mitral valve repair
using the da Vinci robotic system. Ann Thorac Surg. 2004;77(6):1978–82; discussion 1982–
74. doi:10.1016/j.athoracsur.2003.11.024 .
108 L.M. Ocuin and A. Tsung
46. Bokhari MB, Patel CB, Ramos-Valadez DI, Ragupathi M, Haas EM. Learning curve for
robotic-assisted laparoscopic colorectal surgery. Surg Endosc. 2011;25(3):855–60. doi:10.
1007/s00464-010-1281-x.
47. Buchs NC, Pugin F, Bucher P, Hagen ME, Chassot G, Koutny-Fong P, Morel P. Learning
curve for robot-assisted Roux-en-Y gastric bypass. Surg Endosc. 2012;26(4):1116–21. doi:10.
1007/s00464-011-2008-3.
48. Daouadi M, Zureikat AH, Zenati MS, Choudry H, Tsung A, Bartlett DL, et al. Robot-assisted
minimally invasive distal pancreatectomy is superior to the laparoscopic technique. Ann Surg.
2013;257(1):128–32. doi:10.1097/SLA.0b013e31825fff08.
49. Packiam V, Bartlett DL, Tohme S, Reddy S, Marsh JW, Geller DA, et al. Minimally invasive
liver resection: robotic versus laparoscopic left lateral sectionectomy. J Gastrointest Surg.
2012;16(12):2233–8. doi:10.1007/s11605-012-2040-1.
50. Martin RC, Scoggins CR, McMasters KM. Laparoscopic hepatic lobectomy: advantages of a
minimally invasive approach. J Am Coll Surg. 2010;210(5):627–34. doi:10.1016/j.
jamcollsurg.2009.12.022.
51. Cai XJ, Wang YF, Liang YL, Yu H, Liang X. Laparoscopic left hemihepatectomy: a safety
and feasibility study of 19 cases. Surg Endosc. 2009;23(11):2556–62. doi:10.1007/s00464-
009-0454-y.
52. Dagher I, Di Giuro G, Dubrez J, Lainas P, Smadja C, Franco D. Laparoscopic versus open
right hepatectomy: a comparative study. Am J Surg. 2009;198(2):173–7. doi:10.1016/j.
amjsurg.2008.09.015.
53. Abu Hilal M, Di Fabio F, Teng MJ, Lykoudis P, Primrose JN, Pearce NW. Single-centre
comparative study of laparoscopic versus open right hepatectomy. J Gastrointest Surg.
2011;15(5):818–23. doi:10.1007/s11605-011-1468-z .
54. Takahara T, Wakabayashi G, Beppu T, Aihara A, Hasegawa K, Gotohda N, et al. Long-term
and perioperative outcomes of laparoscopic versus open liver resection for hepatocellular
carcinoma with propensity score matching: a multi-institutional Japanese study. J Hepatobiliary Pancreat Sci. 2015;22(10):721–7. doi:10.1002/jhbp.276.
55. Beppu T, Wakabayashi G, Hasegawa K, Gotohda N, Mizuguchi T, Takahashi Y, et al.
Long-term and perioperative outcomes of laparoscopic versus open liver resection for
colorectal liver metastases with propensity score matching: a multi-institutional Japanese
study. J Hepatobiliary Pancreat Sci. 2015;22(10):711–20). doi:10.1002/jhbp.261.
56. Berber E, Akyildiz HY, Aucejo F, Gunasekaran G, Chalikonda S, Fung J. Robotic versus
laparoscopic resection of liver tumours. J Hepatobiliary Pancreat Sci. 2010;12(8):583–6.
doi:10.1111/j.1477-2574.2010.00234.x.
57. Spampinato MG, Coratti A, Bianco L, Caniglia F, Laurenzi A, Puleo F, et al. Perioperative
outcomes of laparoscopic and robot-assisted major hepatectomies: an Italian
multi-institutional comparative study. Surg Endosc. 2014;28(10):2973–9. doi:10.1007/
s00464-014-3560-4.
58. Tranchart H, Ceribelli C, Ferretti S, Dagher I, Patrit A. Traditional versus robot-assisted full
laparoscopic liver resection: a matched-pair comparative study. World J Surg. 2014;38
(11):2904–9. doi:10.1007/s00268-014-2679-8.
59. Troisi RI, Patriti A, Montalti R, Casciola L. Robot assistance in liver surgery: a real advantage
over a fully laparoscopic approach? Results of a comparative bi-institutional analysis.
MRCAS. 2013;9(2):160–6. doi:10.1002/rcs.1495.
60. Wu YM, Hu RH, Lai HS, Lee PH. Robotic-assisted minimally invasive liver resection.
Asian J Surg. 2014;37(2):53–7. doi:10.1016/j.asjsur.2014.01.015.
61. Yu YD, Kim KH, Jung DH, Namkoong JM, Yoon SY, Jung SW, et al. Robotic versus
laparoscopic liver resection: a comparative study from a single center. Langenbecks Arch
Surg. 2014;399(8):1039–45. doi:10.1007/s00423-014-1238-y.
Totally Laparoscopic Right Hepatectomy Combined with En-Bloc Partial Resection of the Inferior Vena Cava
Christophe Bourdeaux, David Fuks and Brice Gayet
Introduction
The practice of laparoscopic liver surgery has grown steadily during the last years,
and many liver resections are now performed laparoscopically[1 - 6].
Laparoscopic liver surgery does not allow the same exposure as performed by
laparotomy, as some areas of the liver are more accessible than others, especially
the most anterior segments. Thus, anatomic resections initially included mainly the
left lobe (segments 2, 3, and 4) and segments 5 and 6 of the right liver [5, 6]. Later,
all types of resect ions were considered (anatomical segmentectomy and major
hemihepatectomies), and left lobe resection from living related donors in the
context of pediatric transplants [7].
Currently, laparoscopic liver resection is feasible and safe when performed in
centers where surgeons are experienced in both liver surgery and laparoscopic
surgery [8]. Further studies, however, seem necessary, especially to determine
long-term oncological results and for major hepatectomy [9]. Regarding colorectal
liver metastasis, laparoscopic resection yields better operative outcomes without
impairing disease-free and long-term survival, and with no difference in terms of
resection margins [10].
9
C. Bourdeaux D. Fuks B. Gayet (&)
Department of Digestive Diseases, Institut Mutualiste Montsouris,
Université Paris Descartes, 42 Boulevard Jourdan, 75014 Paris, France
e-mail: brice.gayet@imm.fr
C. Bourdeaux
e-mail: christophebourdeaux@hotmail.com; c.bourdeaux@cdle.be
D. Fuks
e-mail: david.fuks@imm.fr
© Springer International Publishing AG 2017
T.M. Pawlik et al. (eds.), Case-Based Lessons in the Management of Complex
Hepato-Pancreato-Biliary Surgery, DOI 10.1007/978-3-319-50868-9_9
109
110 C. Bourdeaux et al.
Laparoscopic right hepatectomy is still a challenging abdominal surgical procedure [11], but has become standard in specialized centers [3]. In this setting, we
performed 80 totally laparoscopic right hepatectomies by an anterior approach
between January 2009 and January 2016. While tumor involvement of the inferior
vena cava (IVC) is still considered a contraindication to lapar oscopy. We have a
short experience of 4 cases. The last case is a patient with bilateral colorectal liver
metastases involving the right anterior wall of the retrohepatic IVC who underwent
successful laparoscopic right hepatectomy extended to segment 1 with lateral
resection of the IVC [12]. The case described here illustrates this procedure.
Case Description
A 58-year-old male (BMI 23.24 kg/m2) without previous medical history presented
with synchronous bilateral colorectal liver metastases involving the right anterior
wall of the retrohepatic IVC. Because the primary tumor was symptomatic, a right
colectomy was first performed laparoscopically and the lesion was staged pT4N1M1.
The patient was treated then with nine cycles of chemotherapy (FOLFOX) with a
decrease in the size of the liver metastases. Indeed, after four cycles, imaging
response was adequate for surgery, but chemotherapy was pursued during the whole
strategy.
A contrast-enhanced CT showed one lesion involving segments 8 and 9, with
infiltration of the right anterior wall of the adjacent vena cava (Fig. 9.1). A second
lesion was located in segments 2 and 3 near the root of the left hepatic vein, as
shown in Fig. 9.2.
Because right hepatectomy with en-bloc resection of the involved portion of IVC
would have been required for the first lesion, a two-stage procedure was deemed
necessary as an initial approach, with subsequent left lateral sectionectomy planned
for the second lesion at a second stage.
We will describe here a safe surgical procedure of purely laparoscopic right
hepatectomy extended to segment 1 using an anterior approach with partial IVC
resection.
Patient Positioning
A low lithotomy, i.e., “French position,” with both the legs abducted at the hip and
flexed at the knees and the patient in reverse Trendelenburg position was used
(Fig. 9.3). Other routine precautions like adequate padding of the pressure points
and thermal covers for the exposed limbs should be followed, and were applied to
the case described here.
Trocar Placement
It is difficult to describe a universally accept able trocar position because o f minor
variations needed pertaining to each case. Nevertheless, five trocars are usually
introduced for standard laparoscopic right hepatectomy. The optical trocar should
9 Totally Laparoscopic Right Hepatectomy Combined … 111
Fig. 9.1 A contrast–enhanced CT showed the metastatic lesions of the right lobe, involving
segments 8 and 9, infiltrating the right anterior wall of the adjacent vena cava
Fig. 9.2 A contrast–enhanced CT showed the second metastatic lesion in the left lobe, in
segments 2 and 3 near the root of the left hepatic vein
112 C. Bourdeaux et al.
Fig. 9.3 Shows the patient positioning, a low lithotomy, i.e., “French position,” with both the
legs abducted at the hip and flexed at the knees and the patient in reverse Trendelenburg position
be located high enough to access the hepatic dome, with two trocars just under the
rib, introduced after the establishment of the pneumoperitoneum.
Hand-assist ports can be helpful, especially in case of emergency situations like
bleeding, for surgeons with minimal expertise in advanced laparoscopic procedures
[13]. In patients with colorectal liver metastases, if there is a previous colostomy
then it can be used for gel-ports. In the case described here, the three main working
ports were sited subcostally in the right upper quadrant, and a hand-assisted device
Fig. 9.4 Shows the trocar placement; the three main working ports were sited subcostally in the
right upper quadrant and a hand-assisted device was inserted at the site of the original colectomy
scar. The illustration shows the trocar placement we use for a right hepatectomy
9 Totally Laparoscopic Right Hepatectomy Combined … 113
was inserted at the site of the original colectomy scar, as shown in Fig. 9.4. Apart
from use for specimen retrieval, this port proved very useful in the event of major
hemorrhage.
Surgery
Following insufflation, the abdominal cavity was explored to confirm the absence of
disseminated disease. Intra-abdominal pressure was maintained at 12 mmHg. Of
note, a higher intra-abdominal pressure was avoided due to a potentially higher risk
of gas embolism. A large gauze was placed intra-abdominally, should a compression for haemostasis be necessary in emergency. This can be done through the
hand-assist system without losing intra-abdominal pressure. Intraoperative ultrasound was performed to define the extent of the lesion located at the junction of
segments 8 and 9 involving IVC. The surgery began with the dissection on the
hilum. Cholecystectomy was performed, without removing of the gallbladder, so as
to allow a simple way to grasp and retract the liver. Helped by retraction of the
cystic duct stump, the hilar region was carefully dissected. The posterior right
branches of the bile duct were divided. The hepatic artery and portal vein were
isolated and divided between clips, which was usually performed in this order.
Next, the anterior right branches were divided. Hilar dissection was completed to
allow access to the IVC. Further dissection was continued in this area by dividing
the short hepatic veins and small caudate branches. Her e the laparoscopy enabled a
very clear view of the anterior surface of IVC from the caudate side. With the line
of demarcation established on the liver surface following division of the right
hepatic inflow, parenchymal transection via bipolar electrocautery was commenced
along Cantlie’s line using an ultrasonic scalpel. The tributaries of the middle vein to
segments 5 and 8 were identified, and blood loss was controlled by bipolar electrocautery. Because in this particular case a subsequent left lateral sectionectomy
was planned, the middle hepatic vein was not exposed during the right hepatectomy
in order to prevent potential injury. The location of the second lesion necessitated
the sacrifice of the left hepatic vein, thus leaving the middle hepatic vein as the sole
venous outflow of the remnant liver. The parenchymal transection was continued to
the hepatic vein/IVC junction. This junction was completely cleared with scissor
before the vein was cut using the Endo GIA™ Universal Stapling System.
After the right hepatic vein was divided, the space above the retrohepatic IVC
was opened to allow close inspection, in order to delineate whethere there was
macroscopic involvement of tumor growth or fibrosis. Partial resection of the IVC
was performed by serial applications of the endovascular stapler (Fig. 9.5). Caval
resection can be alternatively accomplished with a non-absorbable monofilament
whipstitch and vascular clamp. All remaining bands tethering the resected specimen
to the diaphragm and retroperitoneum were divided. Haemostasis was verified and
the resected margin was carefully inspected for bile leakage, which was controlled
with monofilament sutures. The specimen was extracted through the hand-assist
system placed on the previ ous incision.
No drainage was used. The surgical duration was 270 min and the blood loss
was 50 ml.
114 C. Bourdeaux et al.
Fig. 9.5 Shows an intraoperative picture of the partial resection of IVC performed by serial
applications of the endovascular stapler. A vascular clamp is always ready and under vision
intracorporeally when using the stapler devices for hepatic veins or IVC
Histological Analysis and Postoperative Course
Histological analysis revealed moderately differentiated adenocarcinoma with a
2 mm surgical margin. The surrounding liver parenchyma showed steatosis. The
postoperative period was uneventful and the patient was discharged after 9 days.
After a selective portal embolization of segment 2 and 3, the segment 4 showed a
volume 515 cc and a full laparoscopic left lateral sectionectomy was performed 7
weeks after the first liver resection. The resection was complete and no adjuva nt
chemotherapy was used.
Tips and Tricks of the Experienced Surgeon
Specific instrumentation for laparoscopic hepatectomy
The laparoscopic liver surgery requires the following specific hardware
(besides the standard equipment of laparoscopic surgery, and open surgery
equipment available if conversion is required):
• Optical at 0° or 30°, or, better, one flexible 3D optical [14]
• Laparoscopic intraoperative ultrasound
• Liver retractor