Abstract
Introduction
Patient and Methods
A 22-year-old woman with a giant angiomyolipoma was referred for surgical treatment. The patient was placed in a left semilateral decubitus position with the surgeon between the patient's legs. Five trocars (three 12 and two 5 mm) were used. The pneumoperitoneum is established at a pressure of 12 mm Hg. Round and falciform ligaments are taken down close to the abdominal wall in order to facilitate left-liver fixation at the end of the procedure. The falciform and coronary ligaments are divided by using laparoscopic coagulation shears (Harmonic Scalpel LCS; Ethicon Endo-Surgery Industries, Cincinnati, OH) to expose the suprahepatic inferior vena cava. After cholecystectomy, the right hepatic artery is ligated, resulting in an ischemic delineation of the right liver. Due to previous right-portal-vein embolization in this patient, the hepatic pedicle was not fully dissected. The right liver is then fully mobilized, and the inferior vena cava is dissected. A large inferior right hepatic vein arising from segment 6 is ligated and divided between metallic clips. Another accessory right hepatic vein from segment 7 (middle-right hepatic vein) is divided with a vascular endoscopic stapler. The right hepatic vein is finally encircled, and downward retraction permits the safe application of a vascular endoscopic stapler. The stapler is fired, leaving three lines of metallic clips. With this maneuver, the anterior surface of the retrohepatic vena cava is completely exposed. The main trunk, including the middle and left hepatic veins, is now the only venous drainage of the liver. It is encircled and traction or temporary clamping permits complete outflow control of the liver, minimizing bleeding during liver transection. At this time, the intrahepatic access to the main right Glissonian pedicle is achieved with two small incisions: An incision is performed on the right portion of the caudate lobe and another anterior incision is made in front of the hilum. An endoscopic vascular-stapling device is inserted between these incisions, and the stapler is fired. All these steps are performed without the Pringle maneuver and without hand assistance.
The line of liver transection is marked along the liver surface, including segment 4. To avoid possible damage to pedicles from segments 2 and 3, the line of transection should be placed 1 cm right from the falciform ligament. The division of the liver parenchyma should be performed under central venous pressure as low as possible. The Glissonian pedicle from segment 4 is divided during liver transection. Liver transection should be performed toward the main trunk to prevent damage to the left hepatic vein. Liver transection is accomplished with a Harmonic Scalpel and endoscopic stapling device, as appropriate. The specimen is extracted through a suprapubic incision, and the pneumoperitoneum is reestablished. Raw surface area is then checked for hemostasia and biliary leakage, and absorbable hemostat tissue (Surgicel; Ethicon Industries, Cincinnati, OH) is applied. The falciform ligament is then fixed to the abdominal wall in order to prevent the remnant liver from rotating spontaneously into the right subphrenic space and causing left-hepatic-vein kinking. 6 One round 19-F Blake abdominal drain (Ethicon) is left in place. The right hepatic trisectionectomy is then completed.
Results
Operative time was 360 minutes, and hospital stay was 7 days. Apart from self-limited biliary leakage, postoperative recovery was uneventful.
Conclusions
Totally laparoscopic right trisectionectomy is safe and feasible in selected patients and should be considered for patients with benign or malignant liver neoplasms. The described technique, with the use of the intrahepatic Glissonian approach and control of venous outflow, may facilitate laparoscopic extended liver resections by reducing the technical difficulties in pedicle control and may diminish bleeding during liver transection.
