Laparoscopic resection of caudate lobe. Technical strategies for a difficult liver segment

Abstract

Background: Caudate lobe of the liver can be divided in three portions: Spiegel lobe, paracaval portion and caudate process. The particular anatomic location of the caudate lobe between the hilar plate and inferior vena cava represents an important obstacle for its laparoscopic removal and a difficult site even for conventional surgery. The aim of this video is to present a laparoscopic resection of the caudate lobe. The area to be removed includes the Spiegel lobe and the paracaval portion. Caudate process is preserved. Methods: A 57 year-old man with colorectal metastasis in segment 1 is referred for surgical treatment. Liver resection is advised and laparoscopic liver resection is proposed. Four trocars are used. The operation begins with complete mobilization of the left liver and ultrasound examination. Lesser sac is open and Arantius ligament is identified and divided. Spiegel lobe is fully mobilized and carefully detached from the inferior vena cava. The pedicle from caudate lobe is identified and controlled. Small veins to vena cava are identified and controlled with bipolar forceps or clips. Dissection progresses towards paracaval portion sparing caudate process (pedicle from right liver). Liver parenchyma is divided with bipolar forceps and resection is completed. Surgical specimen is retrieved through the umbilical incision. No drains are left in place. Results: Operative time was 120 minutes and there was minimal bleeding. Recovery was uneventful and patient was discharged on the third postoperative day. Final pathology showed colorectal metastasis with free margins. Conclusion: Isolate laparoscopic resection of caudate lobe is feasible and can be safely performed in specialized centers. An accurate knowledge of the intricate anatomy of the caudate lobe is essential for the success of this complex operation.