Laparoscopic Right Hepatectomy In A Cirrhotic Patient: Anterior Approach And Extrafascial Pedicle Control

Abstract

Presenter: Jaime Kruger MD | Hospital das Clinicas - University of Sao Paulo Background: Laparoscopic liver resections have gained progressive acceptance among liver surgeons. The second international consensus on minimally invasive liver operations indicated that major liver resections are increasingly being performed. Due to the complexity of such operations, most of them are performed in specialized tertiary academic centers. Along with the complexity of major resections, patient's characteristics such as liver cirrhosis may increase procedure difficulty and demand different approaches in order to successfully perform the operation. Methods: Video describing surgical technique for laparoscopic right hepatectomy. A 53 years-old male patient with hepatitis-C related cirrhosis was diagnosed with a right lobe hepatocellular carcinoma. The patient had normal liver function and no signs of portal hypertension. A totally laparoscopic right hepatectomy was performed, five ports were placed, a 10 mm 30 degree scope was used and pneumoperitoneal was set to 12 mmHg. Due to an enlarged an stiff liver an anterior approach was applied to avoid difficult mobilization and reduce hemodynamic stress. Pedicle was managed with an extrafascial extra hepatic approach and parenchymal transection was carried out with ultrasonic scalpel. Results: Operative time was 360 minutes, estimated blood loss was 500 mL, no blood transfusion was required. Patient was discharged from ICU on 1st POD and from hospital on the 7th POD. The patient developed transient liver insufficiency (5th POD total bilirubin 2.05 mg/dL) and was discharged with improving clinical and biochemical tests. Pathology report confirmed a moderately differentiated HCC, 80 mm in the largest diameter associated with satellite nodules and microvascular invasion. The patient recurred 12 months after resection and was managed with TACE, being alive 30 months after operation. Conclusion: Cirrhotic patients benefit from laparoscopic liver resection, which Results in lesser blood loss and fewer liver-related complications. Anterior approach allows less liver mobilization with theoretical benefits of less hemodynamic stress and fewer microscopic tumor spillage into venous circulation. Extrafascial pedicle control is an interesting technical option for tumors located far from the pedicle as it Results in complete control of the portal triad without prolonged hilar dissection.