Laparoscopic anatomic liver resections for hepatocellular carcinoma

Abstract

Aims: Liver resection is the most important treatment for patients with hepatocellular carcinoma (HCC), offering a possibility of cure. Because of the risk of portal metastases through microscopic vascular invasion, anatomic liver resection is generally assumed to be superior to non-anatomic resection. Aim of the video is to demonstrate how anatomic resections for HCC can be effectively performed laparoscopically thanks to laparoscopic ultrasound (LUS) guidance. Methods: Our technique of LUS guided liver resection is showed. A first scan is performed to complete staging and defining the relationships of the tumor and intrahepatic vasculo-biliary pedicles. To be always aware of the liver anatomy, both in planning the resection and during transection, the planes where main vascular structures run are marked with the electrocautery on the liver surface. When all the vessels are identified and marked, the resection lines are designed on the liver surface with the electrocautery. Results: The first case is a segmentectomy of Sg3. Sg3 pedicle and left hepatic vein are marked. The resection is carried with ultrasound dissector. At the end of the resection left hepatic vein (LHV) is exposed on the liver surface. Segment 2 is spared without any remnant ischemic parenchyma.The second case is a resection of Sg4b. LUS shows the tumor infiltrating a Sg4b main pedicle while superior pedicles are free. Segment 4 superior and inferior pedicles and right hepatic vein (RHV) are marked on liver surface. The resection is completed sparing the superior pedicle of Sg4 and exposing the RHV on the liver surface. The last case is a Sg5 segmentectomy. Two Sg5 pedicles are marked as well as right and middle hepatic vein. The section line is traced along the lines of the structure that will be spared and across the ones that will be cut and the resection is completed. Conclusions: LUS guided laparoscopic anatomic liver resections are feasible and safe.