Laparoscopic Left Hemihepatectomy

(1)

Department of General Surgery, Sir Run Run Shaw Hospital Zhejiang University, Hangzhou, China

Electronic supplementary material

The online version of this chapter at (doi: 10.1007/978-94-017-9840-2_4) contains supplementary material, which is available to authorized users.

Laparoscopic hemihepatectomy is one of the most difficult laparoscopic surgeries and is rarely performed worldwide. In our institute, laparoscopic left hemihepatectomy has been performed as a routine procedure since 2005. The technique of hepatectomy by curettage and aspiration and the selective left inflow occlusion (Fig. 4.1) are the points of this procedure by which the intraoperative blood loss decreases significantly. Total vascular occlusion is the conventional procedure for controlling intraoperative bleeding in open major liver resection and is used in some laparoscopic liver resections (Dulucq et al. 2005; Descottes et al. 2003; Cherqui et al. 2003, 2006). Laparoscopic selective inflow occlusion is more difficult than the total vascular occlusion, but it can avoid the complications of ischemia-reperfusion injury and gastrointestinal congestion (Sahin et al. 2004; Teoh and Farrell 2003; Malassagne et al. 1998). The selective inflow occlusion does not require fast liver transection to decrease the occlusion time allowing surgeons sufficient time for meticulous dissection.

Fig. 4.1

Vascular control in laparoscopic left hemihepatectomy. (A) Selective left inflow occlusion; (B) Occlusion of left hepatic vein

Gas embolism is a dangerous complication of a laparoscopic surgery. In major hepatectomy, the vena cava could be intermittently partly occluded for the compression or the torsion of inferior vena cava (IVC). The venous pressure of the proximal vena cava decreased significantly, and carbon dioxide could be sucked into the vena cava via tears in hepatic veins, which was described as Venturi effect by Hatano et al. (1990). In such a situation, even a small tear in the hepatic vein may lead to the gas embolism. Before liver transection, occluding the hepatic vein of the lobe to be resected should be a good method to avoid this complication. However, occlusion of the left hepatic vein (LHV) before liver transection is a skill-demanding and riskful procedure, which may lead to unmanageable bleeding and emergency conversion. Therefore, we do not carry it out as a routine procedure. It is only performed on selected patients whose LHV is exposed sufficiently and can be dissected safely.

4.1 Indications and Contraindications

The indications include liver tumors in the left lobe or left intrahepatic bile duct stones with irreversible diseases (biliary stricture, severe parenchymal fibrosis or atrophy) requiring left hemihepatectomy and liver function of Child A to B classification. The contraindications include malignant tumor involving porta hepatis, history of biliary surgeries such as exploration of common bile duct or cholangiojejunostomy (cholecystectomy is not regarded as a contraindication), extrahepatic bile duct stricture, or acute suppurative cholangitis.

4.2 Patient Position and Trocars’ Position

Patients are placed in the supine position under general anesthesia. Three surgeons are needed in the operation. As shown in Fig. 4.2, the senior surgeon stands on the left side of the patient, one assistant surgeon stands on the right side of the senior surgeon controlling the aspiration device, and the other assistant surgeon stands on right side of the patient. Four entries are made. A supraumbilical 10-mm trocar is inserted as the observation port. A 12-mm trocar below the left costal margin is inserted as the main manipulation port. And two 5-mm trocars are inserted at the right flank area as assistant manipulation ports.

Fig. 4.2

The trocars’ position and surgeons’ position. (A) Observation port; (B) Main manipulation port; (C) Two assistant ports and the incision for removing specimen; (a) The senior surgeon stands on the left side of the patient; (b) One assistant surgeon stands on the right side of the senior surgeon controlling the aspiration device; (c) The other assistant surgeon stands on the right side of the patient

4.3 Laparoscopic Left Hemihepatectomy with Selective Left Inflow Occlusion and Occlusion of Left Hepatic Vein

See Figs. 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, 4.10, 4.11, 4.12, 4.13, 4.14, 4.15, 4.16, 4.17, 4.18, 4.19, 4.20, 4.21, 4.22, 4.23, 4.24, 4.25, 4.26, 4.27, 4.28, 4.29, 4.30, 4.31, 4.32, 4.33, 4.34, 4.35, 4.36, 4.37, 4.38, 4.39, 4.40, 4.41, 4.42, 4.43, 4.44, 4.45, 4.46, 4.47, and Video 4.1.

Fig. 4.3

The liver is mobilized upward by the traction of the round ligament (RL), and the hepatoduodenal ligament (HDL) is visualized

Fig. 4.4

The lesser omentum (LO) is divided and the caudate lobe (CL) of the liver is visualized

Fig. 4.5

HDL is dissected with a forceps, LPMOD, or the tip of aspiration tube

Fig. 4.6

The left hepatic artery (LHA) is dissected

Fig. 4.7

The LHA is clamped with an absorbable clip

Fig. 4.8

Titanic clips are applied on the distal portion of the LHA

Fig. 4.9

The LHA is divided

Fig. 4.10

After the LHA was divided, the left branch of portal vein (LPV) is visualized

Fig. 4.11

The LPV is freed

Fig. 4.12

The right branch of portal vein (RPV), as well as the portal vein (PV), is visualized, and the bifurcation is identified before the execution of the selective inflow occlusion