Laparoscopic Anatomical Combined Segment 3 and Segment 4 Liver Resection

Abstract

Background: In 1992, Kawasaki et al. reported the first combined segments 3 and 4 liver resection through an open procedure.1 As opposed to a major hepatectomy, this type of liver resection reduces the risk of postoperative hepatic insufficiency, especially in cirrhotic patients. Presently, various types of laparoscopic liver resections are performed in numerous surgical centers. To our knowledge, a combined segments 3 and 4 liver resection through a laparoscopic procedure has not been reported.2–9 This video describes the technical aspects of a totally laparoscopic anatomical combined segments 3 and 4 liver resection using the Glissonian approach. Methods: A 63-year-old woman was referred for a 2.1 cm tumor in segment 4. The tumor was suspected to be a hepatocellular carcinoma and was located deep in segment 4 and adjacent to the Glissonian pedicle of segment 3. The patient had viral hepatitis C, and based on her liver enzymes she was a Child–Pugh class A. Although a left hemihepatectomy could be performed in this case, an anatomical combined segments 3 and 4 liver resection was planned to preserve segment 2 to maximize the remnant liver volume. Technically, the most important aspects of this case included an oncologic resection while preserving the vascular structures to the remnant liver to avoid ischemia in segment 2. Operatively, Glissonian pedicles to segments 2, 3, and 4 (G2, G3, and G4) were dissected proximally. To avoid damaging G2 pedicle, G3 and G4 pedicles were ligated separately with a laparoscopic stapler. A flexible endoscope was used to maximize visualization intra-operatively. After ligating the pedicles, a line of parenchymal demarcation was established along segment 3. Meticulous dissection along the precise ischemic line was performed to prevent injury to the vascular structure of the remnant liver. Ultrasonic shears was used to transect the superficial liver parenchyma, and the deep portion was transected using both laparoscopic cavitron ultrasonic aspirator and electrocautery. After transecting segment 3, segment 4 was dissected along the middle hepatic vein. After ligating the left medial vein from the left hepatic vein, segments 3 and 4 were resected. The specimen was inserted into a vinyl bag and the operative field was irrigated and fibrin glue was applied along the parenchyma. Results: The operation took ~290 minutes and the estimated intraoperative blood loss was 400 mL. No intraoperative transfusion was necessary. On postoperative day 5, a postoperative computed tomogram scan showed no evidence of complications, and the patient recovered with no problems. The final pathology analysis confirmed a cholangiocarcinoma, with a negative resection margin. The patient is alive without adjuvant treatment at 1 year. Conclusion: Laparoscopic anatomical combined segments 3 and 4 liver resection is a feasible operative procedure in patients at risk of hepatic insufficiency. A laparoscopic resection of these segments may be performed without sacrificing large amounts of hepatic parenchyma. No competing financial interests exist. Runtime of video: 6 mins 39 secs This video was presented at the SAGES 2016 annual meeting, held at the Hynes Veterans Memorial Convention Center in Boston, MA.