Laparoscopic Left Hepatectomy for Liver Metastases at a National Cancer Center

Introduction

Since the first report of a laparoscopic liver resection in 1992, laparoscopic resection of peripheral hepatic segments has become increasingly more common in the surgical treatment of both benign and malignant tumors. ¹ The minimally invasive approach to anatomic major hepatectomies, however, is still only being currently performed in highly specialized centers. This is principally because of concerns for gas embolism and difficulty in controlling major hemorrhage via the laparoscopic approach. This video will demonstrate the relevant technical maneuvers in the performance of a totally laparoscopic left hepatectomy, including laparoscopic resection of the caudate lobe.

Methods

Pertinent issues regarding instrument selection, intraoperative monitoring, and steps necessary to perform left hepatectomy (including segments I–IV) using totally laparoscopic techniques will be illustrated.^2,3 The principal steps of this procedure include control of hepatic inflow, division of hepatic parenchyma, control of hepatic outflow, mobilization of the liver, and specimen removal. Pneumoperitoneum with carbon dioxide is obtained to 12–15 torr. The left hepatic artery and duct are clipped before transection, whereas the left portal vein branch is transected with a laparoscopic vascular GIA stapler device (Tri-Staple; Covidien, Norwalk, CT). The Spigelian veins along the underside of the caudate lobe are similarly clipped before transection. The parenchymal transection is performed with a combination of the ultrasonic shears and laparoscopic bipolar device via the technique popularized by Prof. Gayet at the Institut Mutualiste Montsouris in Paris.^4,5 Depending on the patients body habitus, 4–5 trocars are placed ∼1 hand-breadth below the subcostal margin in a semilunar fashion with a final trocar placed 1 finger-breadth below the right subcostal margin for observation during the dissection and transection of the left hepatic vein.^4,5

Two trocar sites are then connected creating a specimen extraction site, a wound retractor is placed in the extraction site, and the specimen is then removed. Alternatively, the specimen can be placed in a specimen retrieval bag and removed via a single trocar site that is enlarged (usually 6–8 cm) to permit removal. Scars of patients with old incisions such as previous cesearean section incisions can also be used. More recently, we have begun using a pfannenstiel incision for specimen removal in female patients without previous lower abdominal surgery.

Results

To date, five totally laparoscopic left hepatic resections have been attempted and five completed laparoscopically (conversion rate = 0%). The average patient age was 60 years (range = 44–69 years) with 3 male and 2 female patients. All resections were for metastases to the liver, four colorectal and one urothelial. Tumors averaged 6.2 cm in greatest diameter (range = 2.7–11.5). The average resection margin was 3.1 cm (range = 1–5.5 cm) with an average of 2 lymph nodes retrieved (range = 0–5). The estimated blood loss was 350 cc (range = 0–1200 cc). The average length of stay was 7 days (range = 4–11 days). No patients required conversion to an open procedure. One patient underwent simultaneous laparoscopic right hemicolectomy, another required simultaneous partial right diaphragm resection with reconstruction, and a third patient also underwent laparoscopic minor resection and microwave ablation to the right hepatic lobe. One patient with multiple preoperative ventral hernias, which were not repaired at the time of liver resection due to concerns of mesh infection, required a ventral hernia repair 1 week postoperatively because of an incarcerated hernia. To date, no patients have developed a clinically detectable air or carbon dioxide embolism.

Discussion

Interventional radiologists use carbon dioxide gas routinely for intravascular contrast. This is because carbon dioxide gas dissolves rapidly in the bloodstream and usually does not cause any clinical sequelae. As a result, because carbon dioxide gas is used to establish pneumoperitoneum during laparoscopic liver surgery, the risk of air embolism may actually be decreased.

Totally, laparoscopic left hepatectomy should currently only be performed by surgeons with expertise in laparoscopy and hepatobiliary surgery. Before embarking on laparoscopic major resections, experience should be gained in laparoscopic hepatic ablations and minor resections. Minimally invasive techniques for left major hepatic resections are feasible, and high-volume centers that specialize in these procedures can have similar oncologic results in terms of margin status and lymph node retrieval when compared to historical open series. Longer follow-up is needed to see if disease-free and overall survival are also similar to open left hepatectomy.