clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

394

SECTION 3

Liver

Procedures

Left Lateral Sectionectomy (bisegmentectomy 2, 3)

This is the most common anatomic liver resection performed laparoscopically.

STEP 1

Access, exploration, and mobilization of the left lateral section

After placement of the ports, the liver is explored by laparoscopic ultrasound to deter-

mine the size and location of the tumor, to detect additional lesions and to assess the

quality of surrounding liver tissue as well as the feasibility of the laparoscopic resection.

First, the round, the falciform, and the triangular ligament need to be divided and the

lesser omentum is opened. The dissection of the falciform ligament is pursued to the

inferior vena cava at the level of the insertion of the hepatic veins. The left triangular

and coronary ligaments are divided.

STEP 2

Preparation for the Pringle maneuver and parenchymal transection

A tape is placed around the porta hepatis and passed through a 16-Fr rubber drain to be

used as a tourniquet secured by a clip (A-1, A-2). The Pringle maneuver is not applied

systematically but is used when required to reduce hemorrhage during transection.

When present, an additional left hepatic artery originating from the left gastric artery

should be either clamped or ligated and divided. Parenchymal transection follows the

left margin of the round and falciform ligament from the anterior edge of the left lateral

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SECTION 3

Liver

STEP 3

Transection of the left hepatic vein and extraction of the specimen

Laparoscopic Liver Resection

397

Non-anatomical or Wedge Resection for a Peripheral Lesion

These resections are for small lesions located on the edge of the anterolateral segments

of the liver (i.e., Segments 3–6).

The liver is exposed and explored as for a left lateral sectionectomy. Although a

Pringle maneuver is rarely necessary for these types of resections, it is a safety measure

to prepare for the possibility of clamping in case of bleeding. The preparation is the

same as for the left lateral sectionectomy.

Resection limits are marked on the liver surface with electrocautery. No wide margins

are required in case of benign lesion, while a 10-mm margin is recommended for malig-

nant tumors of the liver.

Parenchymal transection follows the margins marked on the liver surface by cautery.

Since this is a peripheral resection, the harmonic scalpel (Ethicon EndoSurgery) is

usually very convenient and sufficient. Additional hemostasis is achieved by bipolar

cautery 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.

The specimen is extracted as shown for the left lateral sectionectomy. While the size

of the incision should be adapted to the specimen, port sites >5mm need to be sutured.

398

SECTION 3

Liver

Laparoscopic Living Donor Left Lateral Sectionectomy

for Liver Transplantation in Children

This procedure consists of a laparoscopic left lateral sectionectomy without vascular

clamping or division in order to minimize parenchymal ischemia. General principles

of patient installation and instrumentation are the same as for the left lateral section-

ectomy. The mobilization is the same as for a conventional left lateral sectionectomy.

For open living donor left lateral sectionectomy see chapter by Tanaka and Egawa.

STEP 1

Preparation of the left portal pedicle

The left arterial and portal branches are dissected, encircled, and marked with a vascular

band in the hepatoduodenal ligament (A). Arterial and portal branches to segment 1 are

divided between clips (B).

Laparoscopic Liver Resection

399

STEP 2

Parenchymal transection

In contrast to the conventional resection of the left lateral section, the parenchymal

transection for living donation needs to be performed along the right aspect of the falci-

form ligament. The harmonic scalpel is used for the superficial part of the transection

and the CUSA for deeper transection. Bleeding is controlled only by using bipolar

cautery and clips without any vascular clamping. Segment 4 portal pedicles are divided

inside the liver parenchyma with a linear stapler or clips depending on their size.

STEP 3

Left bile duct division

Once parenchymal transection has reached the hilar plate and the left hepatic duct

becomes visible, the left bile duct is divided using sharp scissors. Its proximal stump

is sutured using absorbable running sutures (PDS 5-0).

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SECTION 3

Liver

STEP 4

End of transection and isolation of the left hepatic vein

Laparoscopic Liver Resection

401

STEP 5

Graft harvesting

An 8–10cm suprapubic, transverse incision is performed in order to extract the left lobe

to be transplanted. Only the skin and subutaneous tissue are opened and a 15-mm trocar

is inserted to fit the extraction bag. The left lobar arterial branch is clipped and divided.

The left portal branch is then divided initiating warm ischemia. In order to preserve an

adequate length of the left portal vein, an Endo-TA stapler (endoTA, Tyco, USA) with

one-sided stapling on the remaining donor liver side is used. In addition, a bulldog is

placed on the side of the graft in order to prevent bleeding. Finally, the left hepatic vein

is stapled with the same one-sided stapling device.

The graft is placed in the bag and extracted through a suprapubic incision after incision

of the fascia as for a conventional left lateral sectionectomy.

The graft is handed to another team for perfusion with the preservation solution.

Warm ischemic time is usually less than 10min.

Final hemostasis and biliostasis remain the same as for the conventional left lateral

resection.

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SECTION 3

Liver

Tricks of the Senior Surgeon

Indications

Malignant liver tumors in the case of:

■

Cirrhosis – if risk of resection is excessive

■

Bilobar disease where resection would not leave enough hepatic parenchyma

■

Debulking of neuroendocrine tumors

■

As an adjunct to resection (i.e., resect one side and cryoablate the other side)

■

Edge cryotherapy when resection margins are less than 1cm

Non-resectable extrahepatic disease (except neuroendocrine tumors)

Contraindications

■

■

High number of lesions (i.e., > nine lesions; other centers may consider > five lesions

as a contraindication)

■

Tumors >5cm

■

Synchronous bowel resection and hepatic cryoablation (increased risk of liver

abscess)