Laparoscopic left hepatectomy for HCC in a cirrhotic patient with right-to-left lobe volume shift

Abstract

Presenter: Jaime Kruger MD | Hospital das Clinicas - University of Sao Paulo Background: Cirrhotic patients derive great benefit of laparoscopic liver resection, mostly related to reduced blood loss and fewer liver-related complications such as hepatic insufficiency, biliary fistula and ascites. Despite being the preferred method for cirrhotic patients, laparoscopic operations might prove difficult when facing a chronically diseased liver, which is in higher risk of blood loss, difficult transection associated with a fibrotic parenchyma and a distorted anatomy secondary to fibrotic and blood flow modifications induced by chronic inflammatory changes. Methods: Surgical technique video describing a laparoscopic left hepatectomy. A 71 years-old patient with hepatitis-C related cirrhosis was diagnosed with a 5 cm hepatocellular carcinoma on the left lobe. There were no signs of portal hypertension, liver function was Chil-Pugh class A/MELD 8. Chronic liver disease resulted in anatomic changes with predominant left-lobe corresponding to 60% of total liver volume. A totally laparoscopic left hepatectomy was performed utilizing 5 ports and a 10 mm 30 degree scope. Transection was carried out with a ultrasonic scalpel after classic hilar approach, dissecting individually arterial and portal venous elements. The left biliary duct was transected intraparenchymally with vascular stapler. Results: Operative time was 180 minutes and estimated blood loss was 100 milliliters. During postoperative recovery the patient developed transient renal disfunction managed conservatively and was discharged on the 7th POD. Pathology report confirmed a 51 mm HCCwith microvascular invasion and free margins (20 mm). Patient is disease-free 12 months after surgery. Conclusion: Chronic changes on the morphology of cirrhotic livers may increase difficulty of laparoscopic liver operations. Even in cases of altered anatomy minimally invasive resections should be pursued as those operations benefit cirrhotic patients and can be safely performed in specialized HPB centers with expertise in laparoscopic liver surgery.