Other Techniques for Laparoscopic Hepatectomy

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

The laparoscopic approach allows patients a rapid return to daily activity and has been adopted almost worldwide. Laparoscopic hepatectomy has developed for two decades, but it is still a developing procedure and is performed only in a few institutes in the world. The liver has rich blood supply, and most intraoperative bleeding could not be effectively managed in a laparoscopic condition which is the major reason hindering the development of laparoscopic liver resection. A technique which could avoid intraoperative bleeding or could significantly decrease the occurrence rate of intraoperative bleeding was highly demanded by surgeons. Until now, the majority of techniques available for laparoscopic liver resection initiated from open procedures. Major changes include the minimization and elongation of instruments to fit laparoscopic manipulation, the modification of surgical procedures, and finally establishing special techniques.

Any technique for laparoscopic liver resection could not leave a special instrument for liver transection. That is to say, an instrument may represent a technique. Apart from LPMOD, there are other instruments used in laparoscopic liver resection, and some techniques are developed based on these special instruments. In this chapter, other techniques and instruments for laparoscopic liver resection will be introduced.

10.1 Laparoscopic Liver Transection with an Ultrasonic Dissector

Patients are usually placed in the lithotomy position. Three surgeons are needed in the operation. The main surgeon stands between the patient’s legs and two assistants stand on each side. Four ports are made. The observation port is placed under or above the umbilicus, and the major manipulation port is usually placed subxiphoid. Firstly, some perihepatic ligaments are divided with the ultrasonic dissector according to the resection extent. Then a transection line is marked on the liver surface, and the liver parenchyma is transected with an ultrasonic dissector along the transection line. Because of the absence of large vessels and hepatic ducts, the superficial liver tissue can be transected directly without dissection which nearly no bleeding or bile leakage occurring (Fig. 10.1). In the transection of deeper liver parenchyma, the ultrasonic dissector should be moved in a “painting” motion (Aldrighetti et al. 2008) along the transection groove for the purpose of detecting large vessels and hepatic ducts without any injury. After vessels or hepatic ducts were detected, they are dissected and freed with the ultrasonic dissector for laparoscopic dissecting forceps and are disposed of depending on their size. Normally, vessels less than 4 mm in diameter could be coagulated and divided with the ultrasonic dissector, and the vessels larger than 4 mm should be clipped or transected with a laparoscopic linear stapler.

Fig. 10.1

Superficial liver parenchyma is transected with a laparoscopic ultrasonic dissector

10.2 Laparoscopic Liver Transection with the Cavitron Ultrasonic Surgical Aspirator (CUSA)

The CUSA is an instrument for dissecting the liver parenchyma. It is a powerful ultrasonic aspirator and dissector and is widely used in surgeries. CUSA has the effect on low-strength tissue and high-strength tissue, and the effect depends on the amount of high-strength intercellular bonds in tissue. It could dissect the liver parenchyma without injuring vessels and bile ducts. The procedure of laparoscopic liver resection with CUSA is similar to the ultrasonic dissector. It has the function of ultrasonic aspiration and irrigation. The action of fragmentation, aspiration, and irrigation could occur simultaneously which allows the surgeon to remove the liver parenchyma with meticulous dissection and accurate transection. CUSA enables the dissection around any structure that needs to be preserved exposing the Glisson capsule, hepatic veins, and vessels across the transection plane for further ligation or clipping (Honda et al. 2013).

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