Caudate lobe of the liver can be divided in three portions: Spiegel
lobe, paracaval portion and caudate process [1]. The particular anatomic
location of the caudate lobe between the hilar plate and inferior
vena cava represents an important obstacle for its laparoscopic removal
and a difficult site even for conventional surgery. Therefore are few
descriptions of this relatively rare procedure [2]. This video shows a
laparoscopic resection of the caudate lobe in a patient with colorectal
metastasis. The area to be removed includes the Spiegel lobe and the
paracaval portion. Caudate process is preserved. We present in this
video the case of a 57 year-old man with colorectal metastasis in segment
1. Liver resection is advised and laparoscopic liver resection is
proposed. Four trocars are used. The operation begins with complete
mobilization of the left liver and ultrasound examination. Lesser sac is
open and Arantius ligament is identified and divided. Spiegel lobe is
fully mobilized and carefully detached from the inferior vena cava. The
Glissonian pedicle from caudate lobe is identified and controlled [3].
Usually this pedicle does not contain major vessels and can be safely
controlled by bipolar forceps. Another option is to encircle the pedicle
and use clips to control it [3]. Small veins to vena cava are identified
and controlled with bipolar forceps or clips. Dissection progresses towards
paracaval portion sparing caudate process (pedicle from right
liver). Liver parenchyma is divided with bipolar forceps with saline
irrigation and resection is completed. Surgical specimen is retrieved
through the umbilical incision. No drains are left in place. Operative
time was 120 minutes and there was minimal bleeding. Recovery was
uneventful and patient was discharged on the third postoperative day.
Final pathology showed colorectal metastasis with free margins. In
conclusion, isolate laparoscopic resection of caudate lobe is feasible and
can be safely performed in specialized centers. Although partial
resection of caudate lobe is technically feasible and may be easier, in
some situations a total caudate lobe resection may be necessary to
obtain free margins. An accurate knowledge of the intricate anatomy of
the caudate lobe is essential for the success of this operation. This video
shows the different steps necessary to perform this complex operationthat are the same as those of the classical ALPPS procedure while reducing invasiveness during the first stage.
Abstract
Laparoscopic resection of caudate lobe. Technical strategies for a difficult liver segment – Video article
Machado MA, Surjan R, Basseres T, Makdissi F
Surgical Oncology 27 (2018) 674–675
https:// doi:10.1016/j.suronc.2018.09.001
Caudate lobe of the liver can be divided in three portions: Spiegel
lobe, paracaval portion and caudate process [1]. The particular anatomic
location of the caudate lobe between the hilar plate and inferior
vena cava represents an important obstacle for its laparoscopic removal
and a difficult site even for conventional surgery. Therefore are few
descriptions of this relatively rare procedure [2]. This video shows a
laparoscopic resection of the caudate lobe in a patient with colorectal
metastasis. The area to be removed includes the Spiegel lobe and the
paracaval portion. Caudate process is preserved. We present in this
video the case of a 57 year-old man with colorectal metastasis in segment
1. Liver resection is advised and laparoscopic liver resection is
proposed. Four trocars are used. The operation begins with complete
mobilization of the left liver and ultrasound examination. Lesser sac is
open and Arantius ligament is identified and divided. Spiegel lobe is
fully mobilized and carefully detached from the inferior vena cava. The
Glissonian pedicle from caudate lobe is identified and controlled [3].
Usually this pedicle does not contain major vessels and can be safely
controlled by bipolar forceps. Another option is to encircle the pedicle
and use clips to control it [3]. Small veins to vena cava are identified
and controlled with bipolar forceps or clips. Dissection progresses towards
paracaval portion sparing caudate process (pedicle from right
liver). Liver parenchyma is divided with bipolar forceps with saline
irrigation and resection is completed. Surgical specimen is retrieved
through the umbilical incision. No drains are left in place. Operative
time was 120 minutes and there was minimal bleeding. Recovery was
uneventful and patient was discharged on the third postoperative day.
Final pathology showed colorectal metastasis with free margins. In
conclusion, isolate laparoscopic resection of caudate lobe is feasible and
can be safely performed in specialized centers. Although partial
resection of caudate lobe is technically feasible and may be easier, in
some situations a total caudate lobe resection may be necessary to
obtain free margins. An accurate knowledge of the intricate anatomy of
the caudate lobe is essential for the success of this operation. This video
shows the different steps necessary to perform this complex operationthat are the same as those of the classical ALPPS procedure while reducing invasiveness during the first stage.