Name: laparoscopic left lateral sectionectomy: guided by the ligamentum teres hepatis and the umbilical fissure vein
Uploaded: 2024-09-27T13:35:00.000+00:00
Duration: 3 min 33 s
Description: Laparoscopic left lateral sectionectomy (LLLS), a mainstream procedure in liver surgery, often utilizes controlled low central venous pressure (CLCVP) to ...

This work was funded by the Bureau of Science &#38; Technology Nanchong City [22JCYJPT0007].

The protocol follows the guidelines of the Human Research Ethics Committee of Nanchong Central Hospital.
1. Pre-operative workup
<ol>
	<li>Perform MRI scanning to confirm the diagnosis and assess the extent of the lesion, bile duct, and vascular anatomy. Perform a magnetic resonance cholangiopancreatography imaging scan on a 3.0 T MRI unit using T2 weighted image thick single-shot fast spin echo/turbo spin echo and fast acquisition relaxation enhancement sequences (Table of Materials).</li>
	<li>Perform the ICG retention test to effectively assess liver function.
	<ol>
		<li>Utilize the liver function reserve analyzer for experimental analysis. Input the patient&#39;s height, body weight, and hemoglobin concentration on the analyzer&#39;s touch screen. The software will automatically compute the required amount of ICG to be injected.</li>
		<li>Subsequently, rapidly inject the ICG through the left median cubital vein, while the nasal probe automatically measures the wavelength of the spectrophotometric spectra. Employ spectroscopic analysis to determine the concentration of ICG, followed by calculating the retention rate after a 10-min injection period8 (Table of Materials).</li>
	</ol>
	</li>
	<li>Extend invitations to surgical, anesthesiology, neurology, and cardiology experts for multidisciplinary consultation to develop surgical strategies, anesthesia management plans, and perioperative medication guidelines.</li>
</ol>
2. Anesthesia
<ol>
	<li>Administer pre-operative antibiotics, typically 1.0 g of ceftazidime (Table of Materials), intravenously on induction of anesthesia.</li>
	<li>Place an arterial line in the patient&#39;s left radial artery and insert a central venous line into the right internal jugular vein.</li>
	<li>Control the intraoperative central venous pressure (CVP) at 5-10 mmHg to ensure cerebral blood perfusion and avoid intraoperative hypotension.</li>
</ol>
3. Patient positioning
<ol>
	<li>Position the patient supine on the operating table in a split-leg position, with the camera assistant standing between the patient&#39;s legs, the first assistant on the patient&#39;s left side, and the surgeon on the patient&#39;s right side.</li>
	<li>Elevate the patient to 30&#176; right lateral position.</li>
</ol>
4. Port site insertion and laparoscope (Figure 2)
<ol>
	<li>Make a longitudinal incision 1 cm below the umbilicus and establish pneumoperitoneum using the Veress needle technique.</li>
	<li>Place 5 mm and 12 mm ports below the costal margin along the left and right anterior axillary lines.</li>
	<li>Place a 12 mm port below the rib cage along the midclavicular line on both the left and right sides.</li>
	<li>Maintain pneumoperitoneum pressure at 10-14 mmHg.</li>
	<li>Perform the procedure using a 30&#176; high-definition laparoscopic device (Table of Materials).</li>
</ol>
5. Operative steps
<ol>
	<li>Mobilization of the left lobe of the liver
	<ol>
		<li>Dissect the hepatic round ligament and falciform ligament using an ultrasonic scalpel (Table of Materials).</li>
		<li>Expose the root of the left hepatic vein. Completely divide the triangular ligament and coronary ligament to expose the root of the left hepatic vein.</li>
	</ol>
	</li>
	<li>Pringle&#39;s maneuver
	<ol>
		<li>Utilize laparoscopic Pringle&#39;s maneuver to apply an extracorporeal tourniquet, and initiate a first porta hepatis block with Pringle&#39;s maneuver if necessary9.</li>
		<li>Employ a grasper posterior to the hepatic pedicle via the foramen of Winslow to facilitate the placement of a cotton tape. Subsequently, extract the ends of the cotton tape through a 5 mm port trocar under the guidance of the grasper.</li>
		<li>Upon removal of the 5 mm trocar, thread one end of the cotton tape through a suction tube and advance into the abdominal cavity up to the level of the hepatic pedicle. Concurrently, maintain the external end of the cotton tape outside the patient&#39;s body.</li>
	</ol>
	</li>
	<li>Left lateral pedicle control via Glissonian approach
	<ol>
		<li>Dissect the superficial peritoneum with an ultrasonic scalpel along the left side of the LTH.</li>
		<li>Dissect the Glissonian pedicles for segments 2/3 from the ventral to the dorsal side.</li>
		<li>Excise the Glissonian pedicles for segments 2/3 with clips (Table of Materials) or a stapler (Table of Materials).</li>
	</ol>
	</li>
	<li>Parenchymal transection
	<ol>
		<li>Dissect the hepatic parenchyma ventrally along the left side of the falciform ligament with an ultrasonic scalpel.</li>
		<li>Use fine-tip forceps and induce energy stimulation to dissect liver parenchyma with an ultrasonic scalpel.</li>
		<li>Dissect the hepatic parenchyma along the UFV within the hepatic parenchyma, facilitating the identification of the root of the left hepatic vein.</li>
		<li>Divide small vessels with the ultrasonic scalpel.</li>
		<li>Divide large vessels or pedicle structures between clips.</li>
	</ol>
	</li>
	<li>Left hepatic vein transection
	<ol>
		<li>Transect the left hepatic vein with a stapler.</li>
	</ol>
	</li>
	<li>Bleeding control
	<ol>
		<li>Perform the first porta hepatis block with Pringle&#39;s maneuver if needed.</li>
		<li>Perform meticulous dissection and identification of intrahepatic vessels.</li>
		<li>Divide hilum and hepatic venules with clips or stapler.</li>
		<li>Use a vascular suture to secure bleeding from vessels.</li>
		<li>Utilize bipolar electrocoagulation forceps to coagulate hemorrhagic points.</li>
	</ol>
	</li>
</ol>
6. Specimen retrieval
<ol>
	<li>Place the specimen into a plastic bag and retrieve it through the subumbilical incision.</li>
</ol>

Laparoscopic Sectionectomy Using Ligamentum Teres for Bloodless Hepatectomy

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J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=International+multicenter+propensity+score+matched+study+on+laparoscopic+versus+open+left+lateral+sectionectomy.">International multicenter propensity score matched study on laparoscopic versus open left lateral sectionectomy.</a> HPB (Oxford). 23 (5), 707-714 (2021).</li><li>Darnis, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+abdominal+wall+benefits+of+the+laparoscopic+approach+in+liver+left+lateral+sectionectomy:+a+multicenter+comparative+study.">Long-term abdominal wall benefits of the laparoscopic approach in liver left lateral sectionectomy: a multicenter comparative study.</a> Surg Endosc. 35 (9), 5034-5042 (2021).</li><li>Chong, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=International+robotic+and+laparoscopic+liver+resection+study+group+investigators.+An+international+multicentre+propensity+score+matched+analysis+comparing+between+robotic+versus+laparoscopic+left+lateral+sectionectomy.">International robotic and laparoscopic liver resection study group investigators. An international multicentre propensity score matched analysis comparing between robotic versus laparoscopic left lateral sectionectomy.</a> Surg Endosc. 37 (5), 3439-3448 (2023).</li><li>Zheng, K., He, D., Liao, A., Wu, H., Yang, J., Jiang, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+segmentectomy+IV+using+hepatic+round+ligament+approach+combined+with+fluorescent+negative+staining+method.">Laparoscopic segmentectomy IV using hepatic round ligament approach combined with fluorescent negative staining method.</a> Ann Surg Oncol. 29 (5), 2980-2981 (2022).</li><li>Wu, H., Xie, K. L., Huang, J., Pan, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+effect+of+fissure+for+ligamentum+teres+hepatic+approach+in+hepatectomy.">Clinical effect of fissure for ligamentum teres hepatic approach in hepatectomy.</a> Chin J Dig Surg. 15 (1), 53-57 (2016).</li><li>Idrees, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Umbilical+fissure+vein,+anatomical+variation+and+potential+surgical+application.">Umbilical fissure vein, anatomical variation and potential surgical application.</a> ANZ J Surg. 91 (7-8), E479-E483 (2021).</li><li>Kobayashi, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Extended+segmentectomy+II+to+left+hepatic+vein:+Importance+of+preserving+umbilical+fissure+vein+to+avoid+congestion+of+segment+III.">Extended segmentectomy II to left hepatic vein: Importance of preserving umbilical fissure vein to avoid congestion of segment III.</a> J Am Coll Surg. 225 (3), e5-e11 (2017).</li><li>Zheng, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+anatomic+bi-segmentectomy+(S3+and+S4b)+using+the+Glisson's+pedicle-first+and+intrahepatic+anatomic+markers+approach.">Laparoscopic anatomic bi-segmentectomy (S3 and S4b) using the Glisson's pedicle-first and intrahepatic anatomic markers approach.</a> Surg Endosc. 36 (10), 7859-7860 (2022).</li><li>Hobeika, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+cirrhosis+in+patients+undergoing+laparoscopic+liver+resection+in+a+nationwide+multicentre+survey.">Impact of cirrhosis in patients undergoing laparoscopic liver resection in a nationwide multicentre survey.</a> Br J Surg. 107 (3), 268-277 (2020).</li></ol>

The authors declare no competing interests.

Management of intraoperative bleeding remains a crucial challenge in laparoscopic hepatectomy. To address this issue, Pringle&#39;s maneuver and the CLCVP technique are commonly employed to control hepatic blood flow10. However, not all patients are suitable candidates for CLCVP, particularly those with concurrent cardiovascular and cerebrovascular diseases.
In this study, we present our experience with laparoscopic hepatectomy in patients with comorbid cerebrovascular disease for whom the CLCVP technique was deemed unfeasible. In summary, the approach involved the dissection of the hepatic parenchyma along the left side of the LTH using an ultrasonic scalpel. The Glissonian pedicles were dissected for segments 2/3 from ventral to dorsal. The hepatic parenchyma was dissected along the left side of the falciform ligament and along the UFV within the hepatic parenchyma to identify the root of the left hepatic vein. Finally, the left hepatic vein was transected using a stapler. Specifically, in the LLLS, we leveraged the enhanced visualization of laparoscopy to meticulously dissect the Glissonian pedicle for segments 2/3 using the LTH approach. Additionally, we utilized UFV as a guide for dissecting branch hepatic veins to control the hemorrhage. The case patient had no perioperative complications despite not undergoing the CLCVP technique.
The surgical approach demonstrated improved precision and better control of intraoperative bleeding than conventional LLLS2. The operation time was 120 min with 50 ml blood loss, which was better than that in previously reported cases11,12,13. Van der Poel et al.11, Darnis B et al.12, and Chong Y et al.13 reported 200, 84, and 672 cases of laparoscopic liver resection, respectively. The average operation times were 144, 189, and 155 min, with 100, 100, and 80 ml blood loss, respectively. The advantages of our technique are as follows: First, it avoids hepatic hilum dissection. Second, during liver parenchymal dissection, utilizing the intrahepatic anatomical landmark of the UFV as a guide prevented the loss of direction.
The initial critical step of this procedure was to isolate the Glissonian pedicle for segments 2/3 via LTH. Xie et al. reported the clinical efficacy of the LTH approach in various hepatectomies, including left lateral sectionectomy, left hemihepatectomy, middle hepatic lobe resection, and right triple hepatectomy, affirming its safety, efficacy, simplicity, and favorable short-term outcomes6. Similarly, Zheng et al. demonstrated the feasibility and effectiveness of the LTH approach in laparoscopic anatomic segmentectomy IV14. The key to this approach is to first utilize the LTH as an anatomical landmark to dissect and ligate the Glissionian pedicle of segments 2/3 outside the liver. This approach offers the advantage of preventing dissection of the first hepatic hilum, thereby reducing the risk of bile duct injury and bleeding, particularly in patients with a history of hepatobiliary surgery or intraoperative hepatic hilum adhesions. Meanwhile, the hepatic hilum may not be blocked, thereby reducing ischemia-reperfusion injury to the liver15.
During hepatectomy within the liver parenchyma, the surgical approach presented here was guided by the UFV. The UFV is a hepatic vein that travels within the umbilical fissure (or its vicinity) and provides venous drainage for liver segments 3 and 4. It is a crucial surgical landmark that should be preserved during left external lobectomy and right triple hepatectomy to avoid residual hepatic parenchyma congestion16,17. Utilizing Glisson prioritization and navigating with intrahepatic anatomical landmarks, including the UFV, in combined laparoscopic segmental hepatectomy (S3 and S4b) has been proposed to be feasible and effective18,19. This approach offers the advantage of achieving the benefits of anatomical hepatectomy while optimizing the postoperative hepatic functional reserve. In our protocol, early identification of the UFV and anatomical resection along the UFV plane minimized the risk of injury to the returning hepatic veins, even without CLCVP. Furthermore, dissection along the UFV prevented the loss of direction during parenchymal dissection and facilitated localization of the root of the left hepatic vein, which ultimately requires dissection.
Nevertheless, these surgical procedures have some inherent limitations. First, in cases involving variations in the UFV, the hepatic parenchyma cannot be separated along the UFV during intrahepatic dissection. Second, this was a complex case of left extrahepatic lobe choledocholithiasis in which the bile duct could not be separated from the UFV owing to severe adhesion of the duct to the UFV.
In summary, we presented an LLLS guided by LTH for the dissection of the Glissonian pedicle for segments 2/3, followed by hepatic parenchymal dissection along the UFV while approaching the left hepatic vein root. LTH- and UFV-guided LLLS effectively control intraoperative bleeding even without CLCVP, suggesting its potential benefit beyond patients with cardiovascular/cerebrovascular conditions, and is widely applicable to all LLLS cases.

Laparoscopic techniques are extensively used in liver surgery and are considered safe and effective. Compared with open surgery, laparoscopic left lateral sectionectomy (LLLS) offers several advantages, including a reduced overall complication rate, shorter postoperative hospitalization, and decreased blood loss1. In the traditional LLLS procedure, the parenchyma is dissected using a harmonic scalpel, starting on the upper liver surface, proceeding from front to back, taking layers 2-3 mm deep ventral and dorsal to the level of the LHV, followed by direct dissection of the left outer lobe hepatic hilum with a staple2. This method may lead to injury of the hepatic parenchyma and veins, thereby increasing the risk of bleeding. The controlled low central venous pressure (CLCVP) technique is often employed in traditional LLLS procedures to mitigate intraoperative bleeding3. However, in patients with concurrent cardiovascular and cerebrovascular diseases, anesthesiologists may opt to avoid using the CLCVP technique to prioritize the perfusion of vital organs4. Herein, we present a standardized procedure for LLLS that does not rely on the CLCVP technique but effectively manages intraoperative bleeding. The key components of the procedure are as follows: (1) utilizing the ligamentum teres hepatis (LTH) approach to control the Glissonian pedicles for segments 2/3; (2) determining the transection plane of the liver based on anatomical landmarks such as the falciform ligament, umbilical fissure vein (UFV), and the canal of Arantius; and (3) using the UFV as a guide for hepatic parenchymal transection to enhance accessibility to the root of the left hepatic vein. The rationale for this technique, which is guided by anatomical landmarks such as the Glissonian pedicle and intrahepatic veins (e.g., UFV), enables more precise lobular and segmental resections while reducing the risk of hemorrhage5. This procedure is straightforward and easy to disseminate and learn. Xie et al.6 and Prof. Sugioka et al.7 have highlighted the safety, effectiveness, simplicity, and anatomical correctness of the LTH approach in hepatectomy procedures. We introduced the LLLS procedure guided by LTH and UFV to further improve the surgical technique.
In this study, we present a representative case to elucidate the procedural steps involved. A 74-year-old male patient presented with chronic upper abdominal pain that had persisted for 3 months. Pre-operative magnetic resonance imaging (MRI) revealed left intrahepatic bile duct stones and localized cystic dilatation of the bile ducts (Figure 1A,B). Additionally, the patient had a history of two cerebral infarctions. Head MRI indicated multiple ischemic and infarct lesions in various brain regions, including the bilateral periventricular regions, basal ganglia, corona radiata, brainstem, and frontal lobes. Notably, lesions in the left basal ganglia and adjacent parts of the right lateral ventricle softened with gliosis. The patient&#39;s Child-Pugh score was 5 (Grade A), and indocyanine green (ICG) retention at 15 min was 6.5%. Based on the radiological features, the patient was diagnosed with left intrahepatic bile duct stones. Subsequently, the patient underwent LLLS.

<table><tbody><tr><td>30&amp;deg; high-definition laparoscopic device</td><td>KARL STORZ,Germany</td><td>26606BCA/ACA</td><td>New 3D Electronic Laparoscope</td></tr><tr><td>Bipolar electrocoagulation</td><td>KANGJI, China</td><td>KJ-XRH05Q</td><td>Electrocoagulation for hemostasis</td></tr><tr><td>Ceftazidime</td><td>Zhejiang Jutai Pharmaceutical Co.,China</td><td>(China) Drug Administration Code (DAC)H20033369</td><td>usage: 1.0 g, intravenous drip</td></tr><tr><td>Computed Tomography (CT)</td><td>Siemens, Germany</td><td>SOMATOM Force</td><td>Force is a 96-row dual-source CT scanner that revolutionizes a series of imaging chains including the tube, high-voltage generator, detector, data acquisition system, and reconstruction system, opening up a new era of CT imaging and achieving faster, wider, thinner, more capable, and lower radiation dose.</td></tr><tr><td>Echelon Flex Endopath Stapler</td><td>Ethicon</td><td>EC60A</td><td>Manual stapler that compresses&lt;br/&gt; tissue while it simultaneously lays&lt;br/&gt; down a staple line and transects the&lt;br/&gt; tissue, 60 mm Stapler (Standard), Size 60 mm, Length 34 cm</td></tr><tr><td>Harmonic ACE+7 Shears</td><td>Ethicon</td><td>HARH36</td><td>Curved tip, energy sealing and&lt;br/&gt; dissecting, diameter 5 mm, length 36 cm</td></tr><tr><td>Hem-o-lok Clips L</td><td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td><td>544240</td><td>Vascular clip 5&amp;ndash;13 mm Size Range</td></tr><tr><td>Hem-o-lok Clips ML</td><td>Weck Surgical Instruments, Teleflex&lt;br/&gt; Medical, Durham, NC</td><td>544230</td><td>Vascular clip 3&amp;ndash;10 mm Size Range</td></tr><tr><td>Indocyanine Green(ICG)</td><td>&amp;nbsp;Dandong Medical Creation Pharmaceutical Co., Ltd.</td><td>H20055881</td><td>25 mg/vial, Detecting liver reserve function</td></tr><tr><td>Liver function reserve analyzer</td><td>Shanghai Optoelectronic Medical Electronic Instruments Co., Ltd</td><td>DDG3300K</td><td>A medical instrument that detects and analyzes indocyanine green (ICG) injected into the body based on spectroscopic analysis techniques.</td></tr><tr><td>Magnetic resonance imaging (MRI)</td><td>GE company,American</td><td>Signa Hoxt 3.0T MRI,JB00988XC</td><td>provides 360-degrees of coil coverage, RF technology, and a direct digital interface with more channels. Patient-friendly design maximizes comfort and system utility, accommodating all types of patients and sizes with feet-first imaging.</td></tr></tbody></table>

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.

In the representative case, the operative time was 120 min with an estimated blood loss of 50 mL, and there were no postoperative complications. The postoperative hospital stay was 7 days. Table 1 summarizes the intra- and postoperative data. A computed tomography(CT) performed on postoperative day 5 revealed no evidence of blood or fluid accumulation in the liver section (Figure 3). The patient was successfully discharged from hospital after surgery. Histological examination of the specimen revealed intrahepatic bile duct stones, accompanied by inflammatory cell infiltration and proliferation of small bile ducts in the porta hepatis region (Figure 4). The patient showed satisfactory postoperative incision healing without infection (Figure 5).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/66907/66907fig01.jpg" /> 
Figure 1: Pre-operative magnetic resonance images. (A,B) The white circles in panels A and B indicate the presence of left intrahepatic bile duct stones along with localized cystic dilatation of the bile ducts. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66907/66907fig01large.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/66907/66907fig02.jpg" /> 
Figure 2: Port placement. The blue solid dots represent ports as follows: A 10 mm sub-umbilical port (camera port), and 5 mm and 12 mm ports at the costal margin along the left and right anterior axillary lines, respectively. Additionally, 12 mm ports were placed in the rib cage along the midclavicular line on both the left and right sides. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66907/66907fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/66907/66907fig03.jpg" /> 
Figure 3: CT scan on postoperative day 5. The white circle indicated the surgical area, and no fluid collection was observed in the surgical liver section. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66907/66907fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/66907/66907fig04.jpg" /> 
Figure 4: Histological examination. Histological examination of the specimen revealed intrahepatic bile duct stones accompanied by inflammatory cell infiltration and proliferation of small bile ducts in the porta hepatis region (100x). Scale bar: 100 &#181;m. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66907/66907fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/66907/66907fig05.jpg" /> 
Figure 5: Postoperative incision healing. Postoperative incision healing without infection. Black arrows indicate the locations of incisions. <a href="https://www-jove-com.bdigitaluss.remotexs.co/files/ftp_upload/66907/66907fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Variables</td>
			<td>Values</td>
		</tr>
		<tr>
			<td>Operating time (min)</td>
			<td>120</td>
		</tr>
		<tr>
			<td>Estimated blood loss (ml)</td>
			<td>50</td>
		</tr>
		<tr>
			<td>Postoperative hospital stay (days)</td>
			<td>7</td>
		</tr>
		<tr>
			<td>Time to first passage of flatus(days)</td>
			<td>3</td>
		</tr>
		<tr>
			<td>First post-operative CT</td>
			<td>Figure 2</td>
		</tr>
		<tr>
			<td rowspan="2">Histopathological examination</td>
			<td>intrahepatic bile duct stones</td>
		</tr>
		<tr>
			<td>inflammatory cell infiltration and proliferation of small bile ducts in the porta hepatis region</td>
		</tr>
		<tr>
			<td>Postoperative incision healing</td>
			<td>Uninfected</td>
		</tr>
	</tbody>
</table>
Table 1: Surgical outcomes.

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: 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 ...

laparoscopic-left-lateral-sectionectomy-guided-ligamentum-teres

Universidad San Sebastian

Research

JoVE Journal

Medicine

730 Views.  the Affiliated Nanchong Central Hospital of North Sichuan Medical College (University). 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.

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

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 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 ...

Cancer Research

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

Re-Arterialized Rat Partial Liver Transplantation with an in vivo Vessel-Oriented 70% Hepatectomy

Split liver transplantation and living liver donor liver transplantation were developed in the clinic to utilize liver organs in a more efficient manner. To better understand the mechanism behind these surgical procedures, a rat partial liver transplantation (PLTx) model was established for relevant surgical studies. Because of the complexity of the rat PLTx model, a protocol with detailed descriptions is required. An article published previously reported a protocol in which ex vivo hepatectomy was used to achieve 50% rat PLTx. In contrast to this protocol, we introduced a re-arterialized PLTx with an in vivo 70% hepatectomy. An updated vessel-oriented hepatectomy was incorporated into the rat PLTx to refine the microsurgical procedure. The portal veins and hepatic arteries of the left lateral lobe and the median lobe were individually dissected and ligated before removal of the liver parenchyma, thereby decreasing the probability of bleeding in the remnant liver stump. Furthermore, an end-to-side vessel anastomosis between the common hepatic artery and the enlarged proper hepatic artery was introduced to re-arterialize the hepatic artery. By using this end-to-side vessel anastomosis technique, the diameter of the anastomosis was enlarged, thereby decreasing the difficulty of hand suture and maintaining a high rate of anastomotic patency. Moreover, the cuff anastomosis of the infrahepatic vena cava was slightly modified. A section of circumferential liver parenchyma around the vena cava of a recipient was preserved during cuff anastomosis to maintain the three-dimensional shape of the vascular lumen. This section of liver parenchyma was removed after completing the anastomosis. With this modification, the step involving placement of stay sutures was omitted, thereby further shortening the cuff anastomosis time. By using this protocol of rat PLTx, a low liver enzyme level, an intact liver lobular architecture and a high survival rate were achieved after microsurgery.

Re-Arterialized Rat Partial Liver Transplantation with an in vivo Vessel-Oriented 70% Hepatectomy

Here, a protocol involving re-arterialized rat partial liver transplantation is presented. Specifically, 70% liver was resected in vivo by using an updated technique of vessel-oriented hepatectomy. The hepatic artery was reconstructed in an end-to-side manner. The cuff technique was modified to shorten the anastomosis time of the infrahepatic vena cava.

Split liver transplantation and living liver donor liver transplantation were developed in the clinic to utilize liver organs in a more efficient manner. ...

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. ...

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.

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 ...

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 Left Approach Resection of the Caudate Lobe

Laparoscopic caudate lobectomy (LCL) is one of the most challenging types of laparoscopic liver resections. The main difficulty lies in the deep anatomical position of the caudate lobe, which is closely adjacent to the first and second hepatic ports and the inferior vena cava, increasing the risk of major bleeding during surgery. In addition to a thorough understanding of the anatomy of the caudate lobe tumor, comprehensive imaging assessment, and three-dimensional reconstruction, the flexible choice of surgical approach is also key to reducing surgical difficulty and improving safety. We perform laparoscopic caudate lobectomy using a left-sided approach, especially when the tumor is located in the area of the caudate lobe close to the inferior vena cava. This method avoids the step of splitting the liver substance to expose the field of view required by the traditional anterior approach, with the advantages of larger operating space and shorter operation time. At the same time, combined with preoperative three-dimensional reconstruction technology, we have significantly reduced the risk of damaging important blood vessels and increased the success rate of resection of tumors in the caudate lobe.

Here, we present a surgical protocol describing the laparoscopic resection of a tumor situated near the paracaval portion within the caudate lobe, utilizing a left-sided approach.

Laparoscopic caudate lobectomy (LCL) is one of the most challenging types of laparoscopic liver resections. The main difficulty lies in the deep ...

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 ...

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

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Chapters in this video

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

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

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

Laparoscopic Anterior Right Hepatectomy: A Single-Center Experience

Re-Arterialized Rat Partial Liver Transplantation with an in vivo Vessel-Oriented 70% Hepatectomy

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

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

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

Laparoscopic Left Approach Resection of the Caudate Lobe

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