Laparoscopic right hepatectomy after portal vein ligation: second step of two stage hepatectomy for colorectal liver metastases

Abstract

Background: Hepatic resection is the treatment of choice for patients with colorectal liver metastases but 75- 85% of patients are unresectable at diagnosis. Many patients with multiple bilobar metastases are not eligible for surgery because of the small future remnant liver (FRL). Patients with impaired hepatic function, scheduled for extended hepatectomy are at greater risk of liver failure. Methods: Two stage hepatectomy (TSH) is a strategy designed to increase the number of patients who may benefit from liver surgery while reducing the risk of postoperative liver failure. Right hepatectomy is now frequently performed laparoscopically, but it may be challenging in the setting of two stage hepatectomy, after left liver clearance and portal vein ligation. Results: The video shows the case of a patient in whom TSH is completed with a laparoscopic right hepatectomy after laparoscopic left liver clearance and PVL. FLR had increased to 49% after portal vein alcohol injection and PLV performed during the first stage. Right hepatic vein is dissected at the caval confluence. Dissection of the right side of the liver pedicle is rather difficult because of the previous PVL. Right hepatic artery and right portal vein are clipped and divided. Parenchimal section is performed with ultrasound dissector. Right bile duct is stapled intraparenchimally. Right hepatectomy is concluded with section of the right hepatic vein. Conclusion: Two stage hepatectomy can performed entirely in laparoscopy in selected patients.