Laparoscopic Resection of the Caudate Lobe

(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_6) contains supplementary material, which is available to authorized users.

The caudate lobe (CL) of the liver is located between the porta hepatis (PH) and the inferior vena cava (IVC). It is divided into three parts: the Spiegel process (SP) (Couinaud’s Segment 1), the paracaval portion (Couinaud’s Segment 9), and the caudate process (CP). The Spiegel lobe is situated behind the ligamentum venosum (LV) and lies on the left of the IVC. The paracaval portion is located in front of the IVC. The caudate process extends to the left and can be used for the traction of the caudate lobe. The caudate lobe is supplied by branches of hepatic artery and portal vein (CPV), and the bile is drained by branches of hepatic duct (HD); these vessels and ducts are called caudate portal triad (CPT). The blood of the caudate lobe usually drains directly into the IVC through the short hepatic veins (SHVs) and, in some cases, drains through the hepatic veins (Fig. 6.1). The CPT and the SHVs are important structures in the resection of the caudate, and in most cases, they can be divided before the transection of the liver parenchyma. It is difficult to define the transection line in the completely isolated caudate lobectomy. Takayama et al. (1991) suggested a counterstaining identification technique to define the surgical margin in 1991, but it was not routinely used in the resection of the caudate lobe. Normally, we performed the resection of the caudate lobe along the line from the caudate process to the tip of the caudate lobe.

Fig. 6.1

Anatomy of the caudate lobe. SIVC suprahepatic inferior vena cava, RHV right hepatic vein, MHV middle hepatic vein, LHV left hepatic vein, SHV short hepatic vein, RPV right branch of portal vein, LPV left branch of portal vein, PV portal vein, CPT caudate portal triad, IIVC infrahepatic inferior vena cava. The red arrow: a left approach to raise the caudate lobe and divide the SHVs. The yellow arrow: the caudate portal triad is dissected and divided, close to the base of the umbilical fissure. The blue arrow: the caudate lobe is transected from the caudate process to the tip of the caudate lobe (From the RPV to the LHV)

Resection of the caudate lobe is one of the most difficult open liver surgeries due to the anatomic position. Proper management of the short hepatic veins is the key to this procedure. In the laparoscopic approach, due to the different vision angle and manipulation space, the short hepatic veins can be fully exposed by the proper mobilization of the caudate lobe and can be safely divided after the meticulous dissection. However, it is still a most dangerous laparoscopic surgery and should be performed by experienced laparoscopic surgeons.

6.1 Indications and Contraindications

The indications include benign liver tumors or intrahepatic bile duct stones with irreversible diseases (biliary stricture, severe parenchymal fibrosis or atrophy) requiring isolated or combined resection of the caudate lobe and liver function of Child A to B classification. Contraindications include extrahepatic bile duct stricture and acute suppurative cholangitis or history of biliary surgeries such as exploration of the common bile duct (CBD), or cholangiojejunostomy (cholecystectomy is not regarded as a contraindication).

6.2 Patient Position and Trocars’ Position

Patients are placed in the supine position under general anesthesia. Three surgeons are needed in the operation. 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 the 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. 6.2).

Fig. 6.2

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 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