This work was supported by grants from the National Natural Science Foundation of China (No. 81971773).

This protocol and surgery video demonstration obtained the patient&#39;s informed consent before surgery, and also obtained approval from The Fifth Affiliated Hospital of Sun Yat-sen University.
1. Preoperative preparation
<ol>
	<li>Perform laboratory tests, including blood routine examination, liver and renal function tests, tumor markers of the digestive system (alpha-fetoprotein, AFP; carcinoembryonic antigen, CEA), prothrombin time, international normalized ratio (INR), and indocyanine green retention rate at 15 min (ICG-R15), to evaluate the general condition of the patients.</li>
	<li>Perform imaging examinations, including a plain thoracic computed tomography (CT) scan, plain and contrast-enhanced upper abdominal CT scan, and liver magnetic resonance imaging (MRI), to evaluate the tumor location, size, and presence of distant metastasis.</li>
	<li>Calculate the hepatic volume by CT volumetry calculation. If patients are considered for performing major hepatic resections (more than two hepatic segments), ensure that the future liver remnant (FLR)/total liver volume (TLV) ratio is &#8805;40%.</li>
	<li>Perform ancillary tests, including electrocardiography (ECG), cardiac ultrasound, and pulmonary function tests, to evaluate the patient&#39;s heart and lung condition.</li>
	<li>Ensure that the patients fully understand their medical condition and are calm enough to achieve good physical and mental preparation for the operation.</li>
</ol>
2. Patient inclusion and exclusion criteria
<ol>
	<li>Inclusion criteria
	<ol>
		<li>Include patients having both primary and secondary liver malignancies, as well as benign liver disease, and require segmentectomy.</li>
		<li>Perform surgery on both males and females between 15-85 years of age.</li>
		<li>Ensure that the patient is in good general condition and can tolerate both anesthesia and laparoscopic hepatectomy.</li>
		<li>Ensure that the preoperative liver function classification according to Child-Pugh is either A or B, the ICG-R15 is &#60;10%, and the FLR/TLV ratio is &#8805;40%.</li>
	</ol>
	</li>
	<li>Exclusion criteria
	<ol>
		<li>Do not include patients with hepatocellular carcinoma with portal and hepatic vein invasion.</li>
		<li>Do not perform surgery on patients with uncontrolled systemic infection.</li>
		<li>Do not perform this surgery if severe portal hypertension has been diagnosed by preoperative CT or endoscopy.</li>
		<li>Ensure that there has been no recent history of gastric or esophageal variceal bleeding, or refractory ascites.</li>
		<li>Ensure there is no diffuse intrahepatic metastasis or distant metastasis.</li>
		<li>Do not perform this surgery in cases where laparoscopic surgery is not feasible due to a history of severe abdominal adhesions resulting from multiple prior abdominal operations.</li>
	</ol>
	</li>
</ol>
3. Surgery
NOTE: As the preoperative MRI revealed that most of the tumor was located in the S5, with a small portion located in the ventral segment of S8 and without any adjacent large blood vessels or bile ducts, S5 and partial S8 removal was planned to ensure a wide resection margin for complete tumor removal. Therefore, ligation of both S5 pedicles and the ventral branches of the S8 pedicles, as well as their branch veins draining into the middle hepatic vein, was planned. The resection was then performed by dissecting the ventral branch of the S8 segment and following along the hepatic pedicle of the S5.
<ol>
	<li>Preparation phase
	<ol>
		<li>Under general anesthesia, place the patient in a supine position, with the legs apart, head elevated, and feet lowered, forming a body angle of 30&#176;.</li>
		<li>Reduce the liquid infusion to 1 mL/kg/h (by the anesthetist) to keep the CVP below 5 cmH2O during the operation.</li>
		<li>Disinfect the abdominal skin with iodine and drape the patient to prepare a sterile field.</li>
		<li>Ensure that the primary surgeon stands on the right, the secondary surgeon stands on the left, and the assistant stands between the patient&#39;s legs.</li>
	</ol>
	</li>
	<li>Trocar placement
	<ol>
		<li>Establish a carbon dioxide pneumoperitoneum of 12-14 mmHg. Insert the trocars according to the location of the tumor.</li>
		<li>For this 54-year-old female patient, establish an observation port by inserting a 10 mm trocar 1 cm below the umbilicus.</li>
		<li>Position two 12 mm trocars bilaterally at the lateral border of the rectus abdominis muscle, 2 cm superior to the umbilicus.</li>
		<li>Position two 5 mm trocars bilaterally below the subcostal margin along the midclavicular line. The trocar layout is shown in Figure 2.</li>
	</ol>
	</li>
	<li>Exploration phase
	<ol>
		<li>Explore the abdominal cavity and omentum to determine whether there are ascites, cirrhosis, intra-abdominal adhesions, or metastases.</li>
		<li>Use laparoscopic ultrasound to evaluate the tumor location, size, and its relationship with adjacent blood vessels or biliary structures, and confirm the preoperative MRI findings regarding the tumor.</li>
	</ol>
	</li>
	<li>Locating the tumor
	<ol>
		<li>Locate the tumor using laparoscopic ultrasound.</li>
		<li>Use an electric coagulation hook to demarcate the area of liver tissue that needs to be excised.</li>
	</ol>
	</li>
	<li>Establishing the extracorporeal Pringle maneuver
	<ol>
		<li>Locate the first porta hepatis and open the omental bursa using a cordless ultrasonic dissector.</li>
		<li>Place another 5 mm trocar (Pringle trocar) in the left hypochondrium along the axillary line. Put the cotton rope into the abdominal cavity through this port.</li>
		<li>Use laparoscopic forceps with an elongated head to horizontally pass the cotton rope through Winslow&#39;s foramen and encircle the hepatoduodenal ligament. Ensure that there are no adhesions behind the hepatoduodenal ligament, so that the forceps and cotton rope can pass horizontally without resistance, avoiding injury to the inferior vena cava and first porta hepatis.</li>
		<li>Pull both ends of the cotton rope through the Pringle trocar using laparoscopic forceps after encircling the hepatoduodenal ligament, and then remove the Pringle trocar.</li>
		<li>Pass the end of the cotton rope through a plastic tube, known as a Lumir device, and insert it up to the level of the hepatic pedicle through the opening where the Pringle trocar was removed. The extracorporeal Pringle maneuver is now ready for application.</li>
		<li>Insert the Lumir device into the cavity to tighten the cotton rope and occlude hepatic inflow, then secure it with a vascular clamp (Figure 2).</li>
	</ol>
	</li>
	<li>Liver parenchyma dissection phase
	<ol>
		<li>Limit the clamping time to 15 min, followed by a 5 min declamping period during the operation.</li>
		<li>Ensure that the secondary surgeon opens the liver capsule along the marked border using an ultrasonic dissector, while the primary surgeon smashes the hepatic parenchyma using a laparoscopic CUSA in an archeological way. Directly cauterize each of the encountered small blood vessels and bile ducts with an ultrasonic dissector, while dividing the large ones after being clamped by Hem-o-lok.</li>
		<li>Dissect the dorsal and ventral branches of the S8 segment within the middle hepatic vein. Clamp and ligate the ventral branch using an Endo-GIA stapler, while preserving the dorsal branch and dorsal segment of the S8.</li>
		<li>Dissect the hepatic vein of the S5 segment and divide it after being clamped by Hem-o-lok.</li>
		<li>Dissect the hepatic pedicle of the S5 segment and cut it with the Endo-GIA stapler. At this point, the planned resection of the liver segments has been successfully completed.</li>
	</ol>
	</li>
	<li>Surgical end stage
	<ol>
		<li>Loosen the cotton rope, cauterize the surgical wound to stop bleeding. Rinse the operation area, drain thoroughly, and cut the cotton rope to remove the Lumir device.</li>
		<li>Cover the operation area with a layer of absorbable hemostat.</li>
		<li>Insert a closed-suction drain.</li>
		<li>Close the abdomen layer by layer.</li>
	</ol>
	</li>
</ol>
4. Postoperative follow-up
<ol>
	<li>Adopt the following management to the patients after returning to the general ward: monitoring of vital signs, intravenous nutrition, rapid recovery of internal organ functions, and prevention of infection and deep venous thrombosis.</li>
	<li>Provide a full-fluid diet and gradually transition to a regular diet over the next few days if the patients have no significant discomfort. Keep the rest of the treatments unchanged for the first 3 days.</li>
	<li>Perform lab examination of the whole blood cells, liver and kidney function, electrolyte levels, and blood coagulation function. Additionally, perform early thoracic and abdominal ultrasounds to check for hydrothorax and ascites.</li>
	<li>Perform a plain upper abdominal CT scan to confirm the absence of residual tumor, bleeding, and bile leakage. Then, remove the drain once the drainage fluid is minimal and clear, which is typically 5-6 days post-operation.</li>
	<li>Patients are typically discharged from the hospital 1 week after surgery and return to the outpatient clinic 1 month later. If necessary, surgeons may take appropriate measures and extend the course of treatment according to the patient&#39;s condition.</li>
</ol>

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The authors report no conflict of interest.

The protocol details a modified LAH performed in our center using the CUSA-ultrasonic dissector-extracorporeal Pringle maneuver technique. In this modified combination technique, we used both the simple extracorporeal Pringle maneuver and a low CVP technique to control and minimize intraoperative bleeding. The primary and secondary surgeons concurrently used a laparoscopic CUSA and ultrasonic dissector, respectively, during parenchymal transection and hemostasis to acquire precise and expeditious hepatectomy.
The perioperative outcomes of the 54-year-old female patient, who was the first to undergo our new combination technique, showed promising results. The operative time was about 145 min, and the intraoperative blood loss was only 150 mL, both better than previously reported results24. In addition, this patient had no major postoperative complications and was discharged within a few days after surgery. Collectively, these data indicate that the new combination technique can offer perioperative advantages, including reduced blood loss, fewer complications, shorter hospital stays, and no increase in mortality for patients who receive LAH.
The traditional single-surgeon technique has limitations in handling intraoperative emergencies, such as unexpected intraoperative bleeding25. However, with the two-surgeon technique, both surgeons can work together to rapidly clear the surgical field and expose and control the bleeding point, so that the emergency treatment can be performed in a shorter time. Studies have shown that the two-surgeon technique is significantly better in terms of shortening operation time and reducing intraoperative blood loss in open and laparoscopic hepatectomy18,22,23. Similar results were also obtained through this technique in our center. In contrast to the traditional single-surgeon technique, the two-surgeon technique places more emphasis on cooperation between the two senior surgeons and their experience. The division of labor between them becomes blurred, and they can swap roles as needed at any time. Therefore, the two-surgeon technique can greatly improve the management of unexpected emergencies during laparoscopic hepatectomy. Moreover, in our center, the CUSA is selected as the primary surgeon&#39;s operative instrument, while the ultrasonic dissector serves as the secondary surgeon&#39;s, which is rarely reported in LAH. Unlike other laparoscopic energy instruments, the CUSA can not only selectively fragment parenchymal tissue while avoiding damaging the blood vessels and bile ducts when properly used, but it can also sever as an aspirator to clean and dry the surgical field when bleeding12,13. During the operation, the primary surgeon uses the CUSA to fragment and aspirate the liver parenchyma, while the secondary surgeon directly transects residual ducts (small blood vessels and bile ducts) with an ultrasonic dissector, or first ligates the ducts (large blood vessels and bile ducts) with Hem-o-lok before using an ultrasonic dissector to cut them off. This significantly accelerates the speed of surgery. The ultrasonic dissector can also be used to stop bleeding on the cut surface of the liver at any time, ensuring a dry operation field. Thorough sharing of roles between two surgeons enables rapid transection of liver parenchyma. The key to successful implementation of this two-surgeon technique is teamwork, with both senior surgeons keeping in mind the transition between transection and hemostasis.
Massive intraoperative bleeding is associated with a high risk of postoperative mortality and a recurrence of liver cancer26,27. Many techniques have been reported to control hepatic inflow and outflow during liver resection16,28, among which the Pringle maneuver and maintenance of low CVP are the most effective and most commonly used techniques nowadays. Previous studies have proposed different kinds of intra- or extra-corporeal Pringle maneuver approaches in laparoscopic hepatectomy. However, the occluding instrumentation and components of each device have not always been consistent16,21,29,30. The occlusion tapes include umbilical tape, cotton tape, tetron tape, and polyester tape. However, each approach has its drawbacks, such as complex manipulation or inadequate blocking of the hepatic pedicle. For example, umbilical or tetron material may lack the elasticity to provide homogeneous power while tightening the hepatoduodenal ligament, resulting in the incomplete occlusion of hepatic inflow. Thus, controlling intraoperative bleeding may not be satisfactory. In addition, some materials may cause a &#34;cutting effect&#34; and damage to the hepatoduodenal ligament.
Herein, we improved the extracorporeal Pringle maneuver by replacing the occluding instrumentation with acotton rope and using a special plastic tube (known as a Lumir device) as an occlusion tube. The cotton rope is soft, elastic, and stronger than single cotton tape. Therefore, it can tighten the hepatoduodenal ligament with homogeneous power to achieve better hepatic inflow occlusion without potentially cutting the portal triad. Moreover, compared with the intracorporeal Pringle maneuver, we can easily block or unblock hepatic inflow by pushing the Lumir device inside or outside. This significantly shortens the processing time and avoids causing unexpected damage when performing the Pringle maneuver during &#34;blind bleeding&#34; periods. We adopted a strategy of 15 min of occlusion followed by 5 min of reperfusion, which has been proven safe for long hepatectomies. The transection surface is carefully checked during every clamp-free interval31. The key step for performing the extracorporeal Pringle maneuver is to horizontally pass the cotton rope, carried by a laparoscopic grasper through Winslow&#39;s foramen, while avoiding injury to the portal vein or vena cava. There should be no resistance when passing tools through Winslow&#39;s foramen, which requires minimal adhesion around the hepatoduodenal ligament. Therefore, one should be cautious with patients who have a history of upper abdominal surgery.
In addition, anesthesiologists must strictly maintain low CVP during hepatectomy, which has been proven fairly effective in controlling and minimizing intraoperative bleeding10,32.&#160;The regulation of CVP requires active communication and cooperation between anesthesiologists and surgeons based on the intraoperative situation. Risks associated with low CVP, such as air embolism and insufficient perfusion of vital organs, should also be considered when maintaining low CVP.
However, centers without a laparoscopic CUSA cannot follow the protocol of this new combination technique. Two senior hepatobiliary surgeons familiar with liver anatomy and surgical procedure are required for this technique. Another limitation is that the occlusion instrument requires additional incisions and is fixed extracorporeally, which sometimes hinders manipulation.
In conclusion, this technique is both safe and feasible. It is easier to achieve a dry and clean operative field, so the bile ducts and blood vessels can be ligated and dissected accurately. Postoperative complications, such as hemorrhage and biliary leakage, are effectively reduced. A wide surgical margin can also be guaranteed with this technique. This method is expected to be a promising surgical technique for patients who receive LAH.

The safety of hepatectomy has significantly improved in recent decades1, and with the rapid advancements in diagnostic imaging, energy devices, and surgical techniques, laparoscopic hepatectomy has become a widely performed procedure that yields favorable clinical outcomes2,3. Studies have demonstrated that anatomical hepatectomy yields superior outcomes compared to nonanatomic resection in patients with hepatocellular carcinoma4,5. Consequently, laparoscopic anatomic hepatectomy (LAH) has gained popularity worldwide6. However, intraoperative hemorrhage remains the primary concern during liver resection procedures-in laparoscopic and open surgeries involving both anatomic and nonanatomic resection7. Besides, intraoperative hemorrhage is the primary cause for conversion from laparoscopic surgery to open surgery during parenchymal transection8,9. To effectively control and minimize intraoperative bleeding, it is widely recommended to maintain the central venous pressure (CVP) below 5 cmH2O in patients undergoing hepatectomy10,11. Additionally, various instruments, such as a cavitron ultrasonic surgical aspirator (CUSA) and an ultrasonic dissector have been utilized12,13, and numerous liver resection techniques, including the liver hanging maneuver14, Pringle maneuver15,16, and the &#34;two-surgeon technique&#34;17,18, have also been documented.
The Pringle maneuver, first reported in 190819, represents the most straightforward technique for hepatic inflow occlusion and is currently readily achievable during laparoscopic hepatectomy with high efficacy20,21.
The two-surgeon technique, proposed as an alternative to the traditional single-surgeon approach, was initially employed in open liver resections17. This method blurs the division of labor between primary and secondary surgeons, with both participating concurrently during parenchymal transection, as well as hemostasis using different energy instruments. Studies have shown that this technique can reduce operation time and intraoperative complications18,22. Takahisa et al. provided us with some recommendations for performing the two-surgeon laparoscopic technique23, but different centers may select different devices to transect the liver parenchymal tissue, and there remains a lack of evidence to demonstrate which mode of the two-surgeon technique yields superior patient outcomes.
The CUSA, a commonly used device in liver resection, employs ultrasonic energy to fragment and aspirate parenchymal tissue, thereby allowing for precision transection with minimal damage to blood vessels and bile ducts13. Another frequently used tool is the ultrasonic dissector, which utilizes the vibrations of two blades to disrupt hydrogen bonds and effectively cut liver parenchyma while coagulating small vessels &#8804;3 mm in diameter13.
In July 2020, our center implemented the two-surgeon technique for the first time. One surgeon used a CUSA while the other used an ultrasonic dissector. This was combined with a simple extracorporeal Pringle maneuver and low CVP technique to treat a 54-year-old female patient who had been experiencing liver mass and an increased serum alpha-fetoprotein (AFP) level of 104 ng/mL for 1 week. Magnetic resonance imaging (MRI) (Figure 1A,B) indicated a tumor measuring about 2 cm in size located in the S5 and S8 segments, which was considered the primary hepatocellular carcinoma. This article presents the protocol of our center&#39;s experience with the CUSA-ultrasonic dissector-extracorporeal Pringle maneuver technique.

<table><tbody><tr><td>1.0 absorbable suture</td><td>Ethicon Inc</td><td>SN2210023642</td><td>Sterile, radiation sterilization, disposable</td></tr><tr><td>1.0 non-absorbable suture</td><td>Ethicon Inc</td><td>SF1AN</td><td>Sterile, radiation sterilization, disposable</td></tr><tr><td>10-mm trocar</td><td>Hangzhou Optoelectronic Equipment Medical Co., LTD</td><td>121-01715</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>12-mm trocar</td><td>Hangzhou Optoelectronic Equipment Medical Co., LTD</td><td>121-01715</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>5-mm trocar</td><td>Hangzhou Optoelectronic Equipment Medical Co., LTD</td><td>121-01715</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>7.0 non-absorbable suture</td><td>Ethicon Inc</td><td>SF7AN</td><td>Sterile, radiation sterilization, disposable</td></tr><tr><td>Aspirator</td><td>Hangzhou Kangji Medical Instrument Co., LTD</td><td>20172080644</td><td>Sterile,dry heat sterilized, reusable</td></tr><tr><td>Cordless Ultrasonic dissector</td><td>Covidien llc</td><td>SCD396</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>CUSA</td><td>INTEGRA</td><td>HDA1902805IE</td><td>Sterile,dry heat sterilized, reusable</td></tr><tr><td>Electric coagulation hook</td><td>Zhejiang Shuyou Instrument Equipment Co., LTD</td><td>IIIA-D003-SG842</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>Endo-GIA stapler</td><td>Jiangsu Guanchuang Medical Technology Co., LTD</td><td>GCJQB-160</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>Endoscopic specimen bag</td><td>Qingdao Huaren Medical Product Co., LTD</td><td>20192060113</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>Hem-o-lok</td><td>Zhejiang Wedu Medical Instrument Co., LTD</td><td>JY1004-2012003</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr><tr><td>Laparoscopic ultrasound</td><td>BK medical</td><td>flex Focus 800</td><td>Sterile,dry heat sterilized, reusable</td></tr><tr><td>Lumir device (modified Pringle maneuver)</td><td>Shanghai Chester Medical Technology Co., LTD</td><td>016651477</td><td>Sterile,dry heat sterilized, reusable</td></tr><tr><td>Surgicel(absorbable hemostat)</td><td>Ethicon Inc</td><td>LAB0011179V3</td><td>Sterile, radiation sterilization, disposable</td></tr><tr><td>Veress needle</td><td>Hangzhou Kangji Medical Instrument Co., LTD</td><td>20172080644</td><td>Sterile, ethylene oxide sterilized, disposable</td></tr></tbody></table>

modified laparoscopic anatomic hepatectomy: two-surgeon technique combined with the simple extracorporeal pringle maneuver

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to the anatomical characteristics of the liver, with intraoperative hemorrhage being a primary concern. Intraoperative blood loss is the leading cause of conversion to open surgery; therefore, effective management of bleeding and hemostasis is crucial for a successful LAH.
The two-surgeon technique is proposed as an alternative to the traditional single-surgeon approach, with potential benefits in reducing intraoperative bleeding during laparoscopic hepatectomy. However, there remains a lack of evidence to determine which mode of the two-surgeon technique yields superior patient outcomes. Besides, to our knowledge, the LAH technique, which involves the use of a cavitron ultrasonic surgical aspirator (CUSA) by the primary surgeon while an ultrasonic dissector by the second surgeon, has been rarely reported before.
Herein, we present a modified, two-surgeon LAH technique, wherein one surgeon employs a CUSA while the other uses an ultrasonic dissector. This technique is combined with a simple extracorporeal Pringle maneuver and low central venous pressure (CVP) approach. In this modified technique, the primary and secondary surgeons utilize a laparoscopic CUSA and an ultrasonic dissectorconcurrently to achieve precise and expeditious hepatectomy. A simple extracorporeal Pringle maneuver, combined with the maintenance of low CVP, is employed to regulate the hepatic inflow and outflow in order to minimize intraoperative bleeding. This approach facilitates the attainment of a dry and clean operative field, which allows for the precise ligation and dissection of blood vessels and bile ducts. The modified LAH procedure is simpler and safer due to its effective control over bleeding as well as the seamless transition between the roles of primary and secondary surgeons. It holds great promise for future clinical applications.

This 54-year-old female patient underwent a successful total laparoscopic anatomic hepatectomy (S5 + S8v) using the CUSA-ultrasonic dissector-extracorporeal Pringle maneuver technique, resulting in favorable perioperative outcomes. During the operation, a total of four extracorporeal Pringle maneuvers were performed to control and minimize intraoperative bleeding. The operation lasted approximately 145 min, with an estimated blood loss of 150 mL. The patient made a rapid recovery, being discharged without complications on the 6th postoperative day. Post-surgical CT imaging showed no residual liver tumor, and the pathological result indicated primary hepatocellular carcinoma with a negative resection margin (Figure 1C,D).
Since 2020, the CUSA-ultrasonic dissector-extracorporeal Pringle maneuver technique has been routinely carried out in our center, and a total of 108 patients have been treated by this means. Here, we retrospectively analyzed 10 patients who received this procedure between July and August in 2021. The median age of these patients was 53.8 years (standard deviation [SD]: 7.73 years; range: 44 to 67 years). They underwent either segmentectomy or subsegmentectomy and received an average of 3.5 extracorporeal Pringle maneuvers during the operation. The operation time and estimated blood loss were fairly good, no patient suffered major intraoperative or postoperative complications, and there were no perioperative deaths. The final histopathological results of all patients were hepatocellular carcinoma (Table 1).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/63555/63555fig01v2.jpg" /> 
Figure 1: Preoperative and postoperative imaging data of the patient. (A) Preoperative diagnostic image of enhanced MRI; the red arrow denotes the tumor. (B)Preoperative diagnostic image of Gd-EOB-DTPA MRI; the red arrow denotes the tumor. (C) Postoperative examination image of enhanced CT. (D) Postoperative pathological image. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/63555/63555fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/63555/63555fig02.jpg" /> 
Figure 2: Trocar and the Lumir device layout. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/63555/63555fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
Table 1: Characteristics of the 10 patients who underwent the CUSA-ultrasonic dissector-extracorporeal Pringle maneuver technique. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/63555/Table 1.xls" target="_blank">Please click here to download this Table.</a>

Watch this Scientific Journal Video about Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver at JoVE.com

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Here, we present a protocol to perform a modified laparoscopic anatomic hepatectomy using improved techniques and instruments.

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to ...

modified-laparoscopic-anatomic-hepatectomy-two-surgeon-technique

Universidad San Sebastian

Research

JoVE Journal

Medicine

2.7K Views.  The Fifth Affiliated Hospital of Sun Yat-sen University. Here, we present a protocol to perform a modified laparoscopic anatomic hepatectomy using improved techniques and instruments.

Video: Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.
The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index &#62;35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.
The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.
The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

Laparoscopic pancreatoduodenctomy (LPD) may offer advantages over open pancreatoduodenectomy, including early postoperative mobilization, less delayed gastric emptying and a shorter hospital stay. However, LPD is technically challenging and not well-standardized, especially regarding the pancreatic anastomosis. We describe a standardized technique for the pancreatic anastomosis during LPD: modified Blumgart pancreaticojejunostomy.

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal ...

Cancer Research

Laparoscopic Left Liver Sectoriectomy of Caroli's Disease Limited to Segment II and III

Caroli's disease is defined as a abnormal dilatation of the intra-hepatica bile ducts: Its incidence is extremely low (1 in 1,000,000 population) and in most of the cases the whole liver is interested and liver transplantation is the treatment of choice. In case of dilatation limited to the left or right lobe, liver resection can be performed. For many year the standard approach for liver resection has been a formal laparotomy by means of a large incision of abdomen that is characterized by significant post-operatie morbidity. More recently, minimally invasive, laparoscopic approach has been proposed as possible surgical technique for liver resection both for benign and malignant diseases. The main benefits of the minimally invasive approach is represented by a significant reduction of the surgical trauma that allows a faster recovery a less post-operative complications.
This video shows a case of Caroli s disease occured in a 58 years old male admitted at the gastroenterology department for sudden onset of abdominal pain associated with fever (>38C&deg; ), nausea and shivering. Abdominal ultrasound demonstrated a significant dilatation of intra-hepatic left sited bile ducts with no evidences of gallbladder or common bile duct stones. Such findings were confirmed abdominal high resolution computer tomography. 
Laparoscopic left sectoriectomy was planned. Five trocars and 30&deg; optic was used, exploration of the abdominal cavity showed no adhesions or evidences of other diseases.
In order to control blood inflow to the liver, vascular clamp was placed on the hepatic pedicle (Pringle s manouvre), Parenchymal division is carried out with a combined use of 5 mm bipolar forceps and 5 mm ultrasonic dissector. A severely dilated left hepatic duct was isolated and divided using a 45mm endoscopic vascular stapler. Liver dissection was continued up to isolation of the main left portal branch that was then divided with a further cartridge of 45 mm vascular stapler.
At his point the left liver remains attached only by the left hepatic vein: division of the triangular ligament was performed using monopolar hook and the hepatic vein isolated and the divided using vascular stapler.
Haemostatis was refined by application of argon beam coagulation and no bleeding was revealed even after removal of the vascular clamp (total Pringle s time 27 minutes).
Postoperative course was uneventful, minimal elevation of the liver function tests was recorded in post-operative day 1 but returned to normal at discharged on post-operative day 3.

This video presents a case of laparoscopic left liver sectoriectomy perfomed in a 53 year old man suffering from Caroli's disease limited to segment II and III of the liver.

Caroli's disease is defined as a abnormal dilatation of the intra-hepatica bile ducts: Its  incidence is extremely low  (1 in 1,000,000 population) and in ...

Biology

Application of Hemostatic Devices in Laparoscopic Hepatectomy

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. Despite its non-invasive aspect, bleeding and bile leakage occur in liver parenchyma tissue resection during the operation or in the post-operation period, indicating the requirement for high-grade hemostatic devices, such as ultrasonic surgical aspiration, bipolar electrocoagulation, etc. The lack of availability of these high-grade hemostatic devices prevents laparoscopic hepatectomy from becoming a generalized procedure in basic medical organizations. In view of the situation mentioned above, a suite of simple and easy hemostatic devices is developed in this protocol, which includes a harmonic scalpel, monopole electrocoagulation, and a single lumen catheter, to innovatively perform liver parenchyma tissue resection. First of all, the porta hepatis or hepatic pedicle is occluded intermittently by a single lumen catheter, followed by clamping for 15 min and releasing for 5 min. Subsequently, using the harmonic scalpel, clamping and crushing of the liver are done to cut off the hepatic parenchyma tissue and to reveal the intrahepatic arteries, veins, and bile ducts. Lastly, the bleeding spots are coagulated by using monopole electrocoagulation at each spot. Intrahepatic pipeline structures are then visible by using these methods, which could stop bleeding easily, reduce the incidence rate of bile leakage, and improve the safety and feasibility of laparoscopic hepatectomy. Therefore, the simple and easy hemostatic devices shown here are suitable for conducting procedures in primary medical institutions.

High-grade hemostatic devices are essential for laparoscopic hepatectomy. However, these devices are not generalized in basic medical organizations. Therefore, a suite of simple and easy hemostatic devices is shown in this article, which can make the laparoscopic hepatectomy easier to perform.

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. ...

Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy

Laparoscopic hepatectomy has been reported in many studies, and it is the mainstream method of liver resection. In some particular cases, such as when there are tumors adjacent to the cystic bed, surgeons cannot palpate the surgical margins through the laparoscopic approach, which leads to uncertainty about R0 resection. Conventionally, the gallbladder is resected first, and the hepatic lobes or segments are resected second. However, tumor tissues can be disseminated in the above cases. To address this issue, based on the recognition of the porta hepatis and intrahepatic anatomy, we propose a unique approach to hepatectomy combined with gallbladder resection by en bloc anatomic resection in situ. Firstly, after dissecting the cystic duct, without cutting the gallbladder primarily, the porta hepatis is pre-occluded by the single lumen ureter; secondly, the left hepatic pedicle is made free by the gap of the Laennec membrane and Hilar plate; thirdly, the assistant is asked to drag the fundus of the gallbladder, and the liver parenchyma tissue is resected using a harmonic scalpel along the ischemia line on the liver surface and intraoperative ultrasound. The whole middle hepatic vein (MHV) and its tributaries appear completely; lastly, the left hepatic vein (LHV) is disconnected, and the specimen is taken out from the abdominal cavity. The tumor, gallbladder, and other surrounding tissues are resected en bloc, which meets the tumor-free criterion, and a wide incisal margin and R0 resection are achieved. Therefore, the laparoscopic hepatectomy with the combination of the en bloc concept and anatomic resection is a safe, effective, and radical method with low postoperative recurrence and metastasis.

Numerous studies have demonstrated the advantages of anatomic resection. Nonetheless, whether anatomic resection can increase R0 resection rates remains controversial. Consequently, the present study describes an innovative procedure involving the en bloc concept combined with anatomic resection in laparoscopic hepatectomy, which can reduce postoperative recurrence and metastasis.

Laparoscopic hepatectomy has been reported in many studies, and it is the mainstream method of liver resection. In some particular cases, such as when ...

Right Hemihepatectomy by Suprahilar Intrahepatic Transection of the Right Hemipedicle using a Vascular Stapler

Successful hepatic resection requires profound anatomical knowledge and delicate surgical technique. Hemihepatectomies are mostly performed after preparing the extrahepatic hilar structures within the hepatoduodenal ligament, even in benign tumours or liver metastasis.1-5. Regional extrahepatic lymphadenectomy is an oncological standard in hilar cholangiocarcinoma, intrahepatic cholangio-cellular carcinoma and hepatocellular carcinoma, whereas lymph node metastases in the hepatic hilus in patients with liver metastasis are rarely occult. Major disadvantages of these procedures are the complex preparation of the hilus with the risk of injuring contralateral structures and the possibility of bleeding from portal vein side-branches or impaired perfusion of bile ducts. We developed a technique of right hemihepatectomy or resection of the left lateral segments with intrahepatic transection of the pedicle that leaves the hepatoduodenal ligament completely untouched. 6 However, if intraoperative visualization or palpation of the ligament is suspicious for tumor infiltration or lymph node metastasis, the hilus should be explored and a lymphadenectomy performed.

This video describes a right hemihepatectomy with intrahepatic transection of the right hemipedicle leaving the hepatoduodenal ligament completely untouched.

Successful hepatic resection requires profound anatomical knowledge and delicate surgical technique. Hemihepatectomies are mostly performed after ...

Laparoscopic Anterior Right Hepatectomy: A Single-Center Experience

Laparoscopic anterior right hepatectomy (LARH) has been used in some hospitals. However, data on the feasibility and safety of this procedure are still limited, due to the demanding technical requirements. The primary objective of this study was to compare the clinical outcomes of LARH with those of laparoscopic conventional right hepatectomy (LCRH) in patients with large right hepatocellular carcinoma, as well as to confirm the safety and feasibility of LARH. Furthermore, the article presents a step-by-step description of the surgical procedures for LARH to help perform this surgery in the clinic. The principle of LARH is to first prioritize the hepatic inlet duct separation while separating the right hepatic perihepatic ligament after transecting the liver. From December 2015 to June 2022, 82 patients with large right hepatocellular carcinoma (maximum tumor diameter &#8805; 5 cm), were recruited for the study. In this cohort, 54 and 28 patients underwent LARH and LCRH, respectively. The perioperative clinical data and survival outcomes of the two groups were compared. Compared with LCRH, LARH exhibited the advantages of less contact and extrusion, thereby leading to the achievement of superior results. Thus, we propose that LARH is the optimal choice for patients with large right hepatocellular carcinoma.

Here we present a step-by-step protocol for conducting laparoscopic anterior right hepatectomy and compare its clinical effects and postoperative outcomes with those of conventional hepatectomies. Analysis of the data of 82 patients with hepatocellular carcinoma revealed that laparoscopic anterior right hepatectomy had better clinical outcomes and survival rates than the conventional hepatectomy.

Laparoscopic anterior right hepatectomy (LARH) has been used in some hospitals. However, data on the feasibility and safety of this procedure are still ...

Behavior

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. Surgery is the cornerstone treatment for patients with BC. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection. In recent years, minimally invasive liver surgery (MILS) including robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. Robotic major MILS is still considered technically demanding and a detailed description of the technical approach during robotic major MILS has only been limitedly discussed in the literature. The current article describes the main steps for a robotic left hepatectomy in a patient with a large BC Todani Type V. The patient is in French position with 5 trocars placed (4 robotic, 1 laparoscopic assistant). After mobilizing the left hemiliver, the left and right hepatic artery are dissected carefully followed by a cholecystectomy. Intraoperative ultrasound is performed to confirm localization and margins of the BC. The Left hepatic artery and left portal vein are isolated, clipped, and divided. Indocyanine green (ICG) fluorescence imaging is used regularly during the entire procedure to visualize and confirm biliary tract anatomy and the BC. Parenchymal transection is performed with robotic cautery hook for the superficial part and robotic cautery spatula, bipolar cautery, and vessel sealer for the deeper parenchyma. The postoperative course was uncomplicated. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging aids in delineating the BC and bile duct anatomy. Further, comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

Advancing LRPS: Optimal Techniques for Challenging Liver Resections

Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver resections, including less blood loss, reduced wound pain, and shorter hospital stays with a comparable oncological outcome. However, laparoscopic resection of lesions in the right posterior section of the liver is challenging due to difficulties in bleeding control and visualizing the surgical field. In the past, laparoscopic right posterior sectionectomy (LRPS) was still in the exploration phase, with undefined risks in the Second International Consensus Conference on LLR in 2014. However, recent technological advancements and increased surgical experience have shown that LRPS can be safe and feasible. It has been found to reduce hospital stay and blood loss compared to open surgery. This manuscript aims to provide a detailed description of the steps involved in LRPS. The key factors contributing to our success in this challenging procedure include proper liver retraction and exposure, the use of an intrahepatic Glissonian approach for inflow control, a technique called the 'ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)' for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy.

Here, we present a protocol to perform laparoscopic right posterior sectionectomy, focusing on two key aspects: the intrahepatic Glissonian approach for inflow control and a parenchymal transection technique using an ultrasonic surgical aspirator.

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver ...

Laparoscopic Sectionectomy Using Ligamentum Teres for Bloodless Hepatectomy

Laparoscopic Left Lateral Sectionectomy: Guided by the Ligamentum Teres Hepatis and the Umbilical Fissure Vein

Laparoscopic left lateral sectionectomy (LLLS), a mainstream procedure in liver surgery, often utilizes controlled low central venous pressure (CLCVP) to reduce bleeding in the hepatic venous system. However, anesthesiologists may avoid the use of CLCVP in patients with concurrent cardiovascular and cerebrovascular diseases to prioritize the maintenance of vital organ perfusion. In this report, we present an LLLS guided by the ligamentum teres hepatis (LTH) for dissection of the Glissonian pedicles for segments 2/3 outside the liver, followed by hepatic parenchymal dissection along the falciform ligament and umbilical fissure vein (UFV) while approaching the left hepatic vein root. Guided by LTH and UFV, this LLLS procedure effectively controlled intraoperative bleeding, even in the absence of CLCVP. Additionally, hepatectomy guided by extrahepatic and intrahepatic anatomical landmarks prevents loss of direction during liver dissection and ensures precise hepatic resection. These attributes suggest that the potential benefits extend beyond patients with cardiovascular or cerebrovascular conditions, making it applicable in a wide range of LLLS cases.

Author Spotlight: Advancing Hepatobiliary and Pancreatic Tumor Treatment with Minimally Invasive Surgical Techniques

Laparoscopic left lateral sectionectomy guided by the ligamentum teres hepatis and umbilical fissure vein effectively controls intraoperative bleeding even without controlled low central venous pressure and prevents loss of direction during parenchymal dissection.

Laparoscopic left lateral sectionectomy (LLLS), a mainstream procedure in liver surgery, often utilizes controlled low central venous pressure (CLCVP) to ...

Peripheral Subtractive Dissection of Glissonean Pedicles in Minimally Invasive Anatomic Liver Resection for Right Posterior Lobe Tumors

Minimally invasive anatomic liver resection (MIALR) has recently garnered significant attention and has rapidly advanced in the field of hepatobiliary surgery. In particular, the dissection of the Glissonean pedicle, such as in Atsushi Sugioka's Gate Theory, represents a fundamental operative technique within MIALR. This technique is based on the anatomical structure of the Laennec capsule, thereby promoting and implementing MIALR in a scientifically rigorous manner. However, potential risks such as hemorrhage, ischemia-reperfusion injury (IRI), and tumor rupture may arise during MIALR in clinical practice, particularly when it is applied to tumors located in the right posterior hepatic lobe near the bifurcation of the Glissonean pedicles (excluding hilar cholangiocarcinoma). To address these challenges, this study introduces a unique surgical approach, termed peripheral subtractive dissection of the Glissonean pedicle (PSDGP), designed to mitigate these potential complications. During the PSDGP procedure in MIALR for liver tumors, the cystic plate approach is utilized to facilitate extrahepatic dissection. Initially, a non-absorbable suture is threaded from Gate VI to Gate IV under the guidance of non-traumatic forceps (or similar instruments). Subsequently, the non-traumatic forceps are passed through Gate V again to retrieve the non-absorbable suture from Gate IV. Finally, both Gate V and Gate VI are used to achieve the separation of the right posterior Glissonean pedicle. This method may improve surgical success rates and yield better oncological outcomes due to its strict adherence to the no-touch and en-bloc principles of tumor resection.

Minimally invasive anatomic liver resection (MIALR) involving Glissonean pedicle ligation for the right posterior hepatic lobe may cause tumor rupture, hemorrhage, and ischemia-reperfusion injury (IRI). This study proposes a novel surgical approach, peripheral subtractive dissection of the Glissonean pedicle (PSDGP), aimed at mitigating these risks.

Minimally invasive anatomic liver resection (MIALR) has recently garnered significant attention and has rapidly advanced in the field of hepatobiliary ...