Laparoscopic Right Posterior Sectionectomy Under Single Incision Plus One Port for Hemangioma

Abstract

Introduction: Laparoscopic right posterior sectionectomy is one of the most technically challenging laparoscopic liver resections.1–5 The single-incision laparoscopic surgery is known to have a highly cosmetic effect, less pain, and shorter hospital stay, but with technical difficulties.6–13 For single incision plus one port surgery, the additional port can be utilized for drainage as well an additional access route for laparoscopic procedures to overcome the technical difficulties. This video demonstrates a laparoscopic right posterior sectionectomy using a single incision plus one port technique. Materials and Methods: A 32-year-old male was evaluated for right upper quadrant pain with a computed tomogram that showed a 9.5 cm sized exophytic hemangioma in segment 6 of the liver. Based on the size and his symptom, surgical resection was recommended. Operatively, the patient was placed in a supine position with the legs split. After making a 3 cm incision through the umbilicus, an additional 12 mm port for the assistant was placed in the right upper abdomen. The surgeon stood between the legs of the patient, while the assistant stood on the right side of the patient. After dividing the cystic duct and artery, the gallbladder and round ligament were fixed to the abdominal wall using Endo-graps (Port-Free Endocavity Retractor; Virtual Ports, Misgav, Israel). The hepatic hilum was dissected bluntly using suction. Then the right posterior Glissonean pedicle was ligated. Without doing the Pringle maneuver, the hepatic parenchyma was dissected meticulously. The additional assistant port was used for liver retraction during deeper parenchyma dissection. After completing the dissection of the liver, the specimen and gallbladder were removed through the umbilical wound. Finally, a Jackson–Pratt drain was placed at the hepatic resection margin through the additional assistant port. Results: This operation took 220 minutes and the estimated blood loss was 100 mL. The Jackson–Pratt drain was removed 2 days after the operation. The patient was discharged 3 days after the operation without any postoperative complications. The final histopathologic report showed a cavernous hemangioma. Conclusions: Although single-incision techniques have been attempted for hepatectomy, posterior sectionectomy is still a technically difficult procedure. Because the posterosuperior part of the liver is difficult to access, any significant bleeding during parenchymal transections can be difficult to control laparoscopically.14 When posterior sectionectomy is performed using a single-incision technique, one additional port can assist to retract the liver and to make clean surgical field by suctioning effectively. Ultimately, this additional port can then be used for the insertion of a drain. Overall, the single incision plus one port laparoscopic surgery can be a new option in right posterior sectionectomy. Acknowledgment: The authors thank Woo Chul Kim, MD, for help in improving the use of English in the article and recording a narration. This video was presented at the Video Exhibition in the HBP Surgery Week 2018, Korea. No competing financial interests exist. Runtime of video: 5 mins 28 secs