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Intrahepatic Glissonian Approach for Laparoscopic Right Trisectionectomy

Marcel Autran Machado, F.F. Makdissi, R.C. Surjan, A.C. Oliveira, V.F. Pilla, A.R. Teixeira

 

Background: Liver resection is the definitive treatment for several benign and malignant liver diseases. Experience with laparoscopic procedures and recent advances in laparoscopic devices have created an evolving interest in the application of these techniques to liver resection1-3. However, laparoscopic liver resections may be technically demanding. Pedicle control is an important step of liver resection. Anatomic hepatectomies usually require extensive hilar dissection. To facilitate pedicle control and to reduce operating time, we have previously described a technique for laparoscopic right liver resections using intrahepatic Glissonian approach4.
Laparoscopic right liver trisectionectomy is a very complex procedure and, to our knowledge, there is only one technical description so far in the English literature5. This video demonstrates technical aspects of a totally laparoscopic right trisectionectomy using intrahepatic Glissonian approach. Our technique differs from that previously described5 by intrahepatic pedicle control and by total control of venous outflow which makes the procedure easier and safer for laparoscopy.
Patient and Method: A 22-year-old woman with a giant angiomyolipoma was referred for surgical treatment. The patient was placed in a left semi-lateral decubitus position with the surgeon between patients’ legs. Five trocars, three 12 mm and two 5mm, were used. Pneumoperitoneum is established at a pressure of 12 mmHg. Round and falciform ligaments are taken down close to the abdominal wall in order to facilitate left liver fixation at the end of the procedure. Falciform and coronary ligaments are divided using laparoscopic coagulation shears (LCS; Ethicon Endo Surgery Industries, Cincinnati, OH, USA) to expose the suprahepatic inferior vena cava. After cholecystectomy, right hepatic artery is ligated resulting in ischemic delineation of the right liver. Due to previous right portal vein embolization, hepatic pedicle is not fully dissected. Right liver is then fully mobilized and the inferior vena cava is dissected. A large inferior right hepatic vein arising from segment 6 is ligated and divided between metallic clips. Another accessory right hepatic vein from segment 7 (middle right hepatic vein) is divided with vascular endoscopic stapler. Right hepatic vein is finally encircled and downward retraction permits safe application of a vascular endoscopic stapler. Stapler is fired leaving three lines of metallic clips. With this maneuver, the anterior surface of retrohepatic vena cava is completely exposed. Main trunk including middle and left hepatic veins is now the only venous drainage of the liver. It is encircled and traction or temporary clamping permits complete outflow control of the liver, minimizing bleeding during liver transection.
At this time intrahepatic access to the main right Glissonian pedicle is achieved with two small incisions: an incision is performed on the right portion of caudate lobe and another anterior incision is made in front of the hilum. An endoscopic vascular stapling device is inserted between these incisions, and the stapler is fired. All this steps are performed without the Pringle maneuver and without hand assistance.
Line of liver transection is marked along the liver surface including segment 4. To avoid possible damage to pedicles from segments 2 and 3, the line of transection should be placed 1 cm right from falciform ligament. The division of the liver parenchyma should be performed under central venous pressure as low as possible. Glissonian pedicle from segment 4 is divided during liver transection. Liver transection should be performed towards the main trunk to prevent damage to the left hepatic vein. Liver transection is accomplished with harmonic scalpel and endoscopic stapling device as appropriate. The specimen is extracted through a suprapubic incision and pneumoperitoneum is reestablished. Raw surface area is then checked for hemostasia and biliary leakage and absorbable hemostat tissue (Surgicel; Ethicon Industries, Cincinnati, OH, USA) is applied. Falciform ligament is then fixed to the abdominal wall in order to prevent the remnant liver to rotate spontaneously into the right subphrenic space and cause left hepatic vein kinking6. One round 19F Blake abdominal drain (Ethicon, Inc, Cincinnati, Ohio) is left in place. Right hepatic trisectionectomy is then completed.
Results: Operative time was 360 minutes and hospital stay was 7 days. Apart from self-limited biliary leakage, postoperative recovery was uneventful.
Conclusion:  Totally laparoscopic right trisectionectomy is safe and feasible in selected patients and should be considered for patients with benign or malignant liver neoplasms. The described technique, with the use of intrahepatic Glissonian approach and control of venous outflow, may facilitate laparoscopic extended liver resections by reducing the technical difficulties in pedicle control and may diminish bleeding during liver transection.

References

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