Open right hepatectomy for hepatocellular carcinoma via anterior approach

Abstract

Introduction: Anterior approach is a well-established technique for large, challenging hepatocellular carcinoma (HCC) in the right liver. Improved oncologic outcomes and disease-free survival is attributed to decreased manipulation of the tumor prior to vascular ligation and parenchymal transection. We present the case of a large HCC safely resected with an anterior approach. Method: A 66-year-old gentleman presented with weight loss, fatigue and right upper quadrant (RUQ) pain. Imaging was consistent with 13.6cm HCC and underlying liver disease. The tumor replaced much of the right liver. Initial future liver remnant (FLR) to total liver volume (TLV) ratio was 30%. Given the underlying liver disease, the patient underwent portal vein embolization with FLR hypertrophy, resulting in FLR/TLV ratio of 44%. The patient proceeded with open right hepatectomy via anterior approach. Results: Abdominal access is obtained through an extended J-shaped thoracoabdominal incision to maximize RUQ exposure. The inferior coronary ligament is opened to isolate the inferior vena cava (IVC). A Rummel tourniquet is placed, to be applied during dissection if necessary. Extrahilar dissection was performed, followed by transection of the right hepatic artery and right portal vein. The latter is closed with continuous suture to avoid stapling across embolization material. Parenchymal transection is performed via anterior approach—with an ultrasonic dissection device for parenchyma, and clips and sutures for structures—using the middle hepatic vein identified on intraoperative ultrasound as the resection margin. The right main pedicle is identified intrahepatically and divided with a stapler. Due to backbleeding, the tourniquet is temporarily applied on the IVC, allowing safe division of the right hepatic vein and branches from the middle hepatic vein. An omental patch is placed at the bed of transection. The patient tolerated procedure well, with estimated blood loss of 200mL. Conclusion: Anterior approach for large HCC is associated with improved perioperative morbidity and mortality as compared to conventional approach with posterior mobilization. IVC clamping is an established technique for controlling hepatic vein backbleeding, particularly in the anterior approach to reduce blood loss.