(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_8) contains supplementary material, which is available to authorized users.
The safety of liver resection mainly depends on the function of the future liver remnant (FLR). Inadequate volume of FLR is associated with a significant increase in postoperative liver failure, especially in patients with liver cirrhosis. Even though laparoscopic hepatectomy could decrease the surgical trauma, it still could not solve the problem of inadequate volume of FLR. In clinical practice, surgical indications for patients with small volumes of FLR are always difficult to make because of the conflict between safety and oncological radicality. Two effective methods for increasing volume of FLR are adopted. One is portal vein ligation or percutaneous portal vein embolization, and the other is a two-stage surgery. However, these methods require several weeks for liver regeneration before the resection of liver malignancy. The risk of tumor progression during the waiting time is of concern by surgeons (Hayashi et al. 2007; Kokudo et al. 2001). Recently, a new “two-stage” operation which was named as “associating liver partition with portal vein ligation for staged hepatectomy (ALPPS)” by de Santibañes and Clavien (2012) has drawn the attention of surgeons. This method enables the rapid growth of FLR. However, the complication of bile leakage increased. In Schnitzbauer’s report (Schnitzbauer et al. 2012), bile leakage was observed in 24 % of the patients and the mortality was 12 %. The safety of the ALPPS was questioned by some surgeons (Kokudo and Shindoh 2013). The procedure of the in situ splitting of the liver was supposed to the major cause of the high occurrence rate of biliary leakage. This procedure was modified by Robles Campos et al. (2013). A round-the-liver ligation was executed to replace liver splitting to avoid the complication of biliary leakage and simplify the procedure as well (Fig. 8.1).


Fig. 8.1
Placement of the round-the-liver ligature in the two-stage completely laparoscopic left hemihepatectomy (a) and the two-stage completely laparoscopic right hemihepatectomy (b). (a) Abdominal wall; (b) Thoracic tube; (c) Round-the-liver ligature
Totally laparoscopic ALPPS was described by Machado et al. in a letter to the editor in 2012. Differing from his cases, we adopted the execution of the round-the-liver ligation to replace the in situ splitting of the liver that could avoid postoperative bile leakage and might simplify the operation. Laparoscopic meticulous dissection is the point of the first-stage operation. The aspiration tube and 90°-angle forceps are good instruments for blunt dissection which could safely free the branches of portal vein (PV) and hepatic veins. The ligation would become loose after the first-stage operation for the gradual atrophy of the liver parenchyma under the ligature, so it is necessary to tighten the ligation a few days after the first-stage operation.
In 2014, completely laparoscopic ALPPS using round-the-liver ligation was performed on patients with an estimated volume of FLR lower than 40 % to achieve a radical resection of multiple liver malignancies, and a rapid increase of FLR volume was observed. Theoretically, the advantage of minimal invasion of laparoscopic surgery would decrease surgical trauma and lead to a lower occurrence rate of postoperative liver failure. The adoption of round-the-liver which replaced liver splitting could avoid biliary leakage and simplify the first-stage operation and finally could lead to decreases in perioperative morbidity and mortality. However, this procedure is still in the exploration stage. The value of this procedure should be further evaluated.
8.1 Indications and Contraindications
Indications include liver tumors requiring left hemihepatectomy, estimated volume of FLR lower than 40 %, and with liver cirrhosis and liver function of Child A to B classification. The contraindication is malignant tumor involving porta hepatic (PH).
8.2 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 is inserted below the xiphoid as the main manipulation port for right liver lesions or is inserted below the left costal margin for left liver lesions. And two 5-mm trocars are inserted at the right flank area as assistant manipulation ports (Fig. 8.2).


Fig. 8.2
Trocars’ position and surgeons’ position. (A) Observation port; (B 1) Main manipulation port for right liver lesions; (B 2) Main manipulation port for left liver lesions; (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
8.3 Two-Stage Laparoscopic Left Hemihepatectomy
The first-stage operation: laparoscopic ALPPS using round-the-liver ligation (Figs. 8.3, 8.4, 8.5, 8.6, 8.7, 8.8, 8.9, 8.10, 8.11, 8.12, 8.13, 8.14, 8.15, 8.16, 8.17, 8.18, 8.19, 8.20, 8.21, 8.22, 8.23, 8.24, 8.25, 8.26, 8.27, 8.28, 8.29, 8.30, 8.31, and Video 8.1).





























Fig. 8.3
The patient has severe liver cirrhosis due to a hepatitis B infection and the hepatocellular carcinoma in the segment IV which was confirmed by liver biopsy. The estimated volume of FLR is 38.8 %, and his liver function classification is Child A

Fig. 8.4
The liver is mobilized upward, and the hepatoduodenal ligament (HDL) is dissected with LPMOD

Fig. 8.5
The lesser omentum (LO) is partly divided with LPMOD

Fig. 8.6
The left hepatic artery (LHA) is visualized in the dissection of hepatoduodenal ligament

Fig. 8.7
The LHA is freed with a 90°-curved dissecting forceps

Fig. 8.8
An elastic tape is passed through the back of the LHA

Fig. 8.9
Another elastic tape is passed through the back of the proper hepatic artery

Fig. 8.10
The proper hepatic artery and the LHA are mobilized to the left, and the portal vein (PV) is exposed

Fig. 8.11
The left branch of the portal vein (LPV) is dissected with LPMOD, and the bifurcation of the portal vein (BPV) is identified

Fig. 8.12
The LPV is freed with a 90°-curved dissecting forceps

Fig. 8.13
A suture is passed through the back of the LPV with the guidance of the curved dissecting forceps

Fig. 8.14
The LPV is ligated

Fig. 8.15
An absorbable clip is applied on the LPV to secure the ligation

Fig. 8.16
The view of the LPV after being ligated and clamped

Fig. 8.17
The adhesion and the falciform ligament (FL) are divided with LPMOD

Fig. 8.18
The left coronary ligament (LCL) is divided with LPMOD

Fig. 8.19
The left triangle ligament (LTL) is divided with a ultrasonic scalpel

Fig. 8.20
The lesser omentum is further divided with the ultrasonic scalpel

Fig. 8.21
The LCL is further divided with LPMOD

Fig. 8.22
The LHV is freed with the 10-mm 90°-curved dissecting forceps

Fig. 8.23
The round-the-liver ligature, a nasogastric tube with a guide wire inside, is passed through the back of the LHV with the guidance of the curved dissecting forceps

Fig. 8.24
The round-the-liver ligature has passed through the back of the LHV

Fig. 8.25
The round-the-liver ligature is rounded the left lobe (LL) of the liver

Fig. 8.26
The round-the-liver ligature is passed through the back of the left hepatic artery with the guidance of the curved dissecting forceps

Fig. 8.27
The round-the-liver ligature has been passed through the back of the left hepatic artery

Fig. 8.28
The round-the-liver ligature is rounded the left lobe and is extracted outside the abdominal cavity through the 12-mm manipulation port

Fig. 8.29
After elastic tapes were removed, a suture is placed around the LHA for the second operation

Fig. 8.30

A thoracic tube is inserted through the 12-mm trocar, and both ends of the ligature are passed through the thoracic tube. Laparoscopic ultrasound is performed to guide the placement of the round-the-liver ligature

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