Laparoscopic extended posterior sectorectomy for metastatic adrenocortical carcinoma: a minimally invasive approach to parenchymal preservation

Abstract

Background: Parenchymal preservation contributes to improved morbidity and mortality after hepatic resection. Additionally, randomized data supports minimally invasive (MIS) approaches to hepatic resection, resulting in shortened hospitalization, reduced postoperative morbidity, and improved quality of life. The Wakabayashi complexity index for laparoscopic hepatectomy guides patient selection, but the combination of MIS and parenchymal preservation for complex hepatic resections is seldom performed. Methods: A 65-year old male with adrenocortical carcinoma was treated with a laparoscopic left adrenalectomy in 2012. Surveillance MRI 5 years later identified a new 1.7 cm lesion located adjacent to the right hepatic vein in segment 7 (Figure). Percutaneous biopsy was consistent with metastatic adrenocortical carcinoma. Given the prolonged disease-free interval, extended right posterior sectorectomy was recommended. Results: The patient was placed in a split leg French position. A 3-D laparoscope was used and 4 port sites were required. Taking advantage of patient anatomy, the right posterior hepatic artery and portal vein were ligated and divided within the porta hepatis. The translation of open parenchymal transection techniques with crush-clamping, energy, and staplers facilitated safe laparoscopic dissection between the anterior and posterior sectors, with control of intrahepatic vascular structures and ultimate division of the right hepatic vein at its origin. Conclusion: Parenchymal preservation leveraging MIS technique facilitated complete resection of an isolated adrenocortical carcinoma metastasis. Laparoscopic extended posterior sectorectomy allowed for rapid progression through postoperative milestones with early discharge and salvage of the majority of the anterior sector, thereby reducing this patient’s risk for postoperative liver failure and mortality.