How I divide the liver parenchyma in cirrhotic livers with minimally invasive surgery

Abstract

Presenter: Michael Jureller MD | Montefiore Medical Center Background: Case 1is a 68 year old female with compensated hepatitis C virus (HCV) cirrhosis and 2 hepatocellular carcinoma (HCC) lesions. A 15mm LIRADS-4 lesion in segment 8 and a 2cm LIRADS-5 lesion in segment 6. She was not a transplant candidate. Laparoscopic approach in left lateral decubitus position is used to facilitate exposure. The lesion in segment 8 was deep, so it received laparoscopic microwave ablation to avoid major hepatic resection. The segment 6 lesion was superficial and visible. It was approached for wedge resection using monopolar energy to score the capsule. The parenchymal division was carried out with LigaSure device. A hepatic vein branch that is seen during transection but not well controlled with LigaSure, so it was reinforced after resection with a V-Loc suture, achieving hemostasis. This highlights a simple approach for a cirrhotic liver, like any other liver wedge, but with the addition of suture to achieve hemostasis. Case 2 is robotic segment 5 resection a 68 year old woman with compensated HCV cirrhosis and a 2 cm LIRADS-5 lesion. She had a remote history of a prior open cholecystectomy and subsequent incisional hernia repair. She refused non-surgical options such as ablation, transarterial chemoembolization and radiation. A robotic approach was preferred to navigate the adhesions and for a better targeted resection. The lesion was identified with intraoperative ultrasound, and a Pringle setup was prepared. Resection was carried out with monopolar energy to score the capsule, and the parenchyma was divided by combining a Maryland bipolar and vessel-sealer. We encountered is significant portal vein bleeding during the parenchymal division. It was managed with simple compression first and then activating the Pringle maneuver without the need to leave the console. The cut surface was treated with bipolar energy. Case 3 is a 65 year old man with HCV cirrhosis and a 3.5 cm LIRADs-5 HCC on the surface of segment 2. A laparoscopic approach for left lateral sectionectomy was preferred over a robotic approach given the nodularity of the liver, suggestive of significant scarring around major vessels and the availability of the CUSA as the most reliable tool for vascular dissection during parenchymal division. We show during our transection that the CUSA is able to facilitate the dissection around vessels clearing the way for the vascular stapler to transect vessels without risking failure due the presence of scarred liver parenchyma. The old fashioned bipolar forceps pairs really well with the CUSA for treating the cut surfaces.