Laparoscopic caudate lobe re-resection in an obese patient with cirrhosis: a himalayan approach

Abstract

We present the video of a laparoscopic caudate lobe repeat resection for a bifocal hepatocellular carcinoma (HCC) recurrence in a 67-year-old male with a history of HBV-, HCV- and metabolic-related cirrhosis, obesity, type-II diabetes, hypertension. The patient had previously undergone a partial laparoscopic resection of the caudate process with cholecystectomy in 2016 for a 55 mm G2 HCC. After four years, follow up CT and MRI showed a bifocal HCC recurrence of 22 and 10 mm in the paracaval portion of the remaining caudate process. After extensive adhesiolysis and caval exposure, the lesser omentum and accessory left hepatic artery were sectioned to expose the caudate lobe, which was then detached from the plane of the inferior vena cava by sectioning the Spigelian veins. During this maneuver, a clip on a 4mm Spigelian vein fell, causing a bleeding that was controlled with forceps and repaired with a 3/0 Polyglactin running suture. Half-way through the parenchymal transection, the pneumoperitoneum was interrupted due to insufflation problems. At reinsufflation, the patient went into cardiac arrest. CPR was performed, with return of spontaneous circulation after one minute. Cardiolpulmonary events were excluded but, due to worsening acidosis, the operation was interrupted and the patient was taken to the ICU for monitoring and stabilization. The next day, after a night of bivouac and lactate clearance, the operation was concluded as a hand-assisted procedure. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. Histological examination showed a bifocal pT2 G1 HCC.