The “Dorsal” approach to laparoscopic major hepatectomy enables expanded indications for laparoscopic liver resection

Abstract

Introduction: This new technique, a modification of the caudal approach of Soubrane, involves a posterior to anterior transection of the liver for laparoscopic major hepatectomies. It was conceived to enable a standardised technique, and to broaden the indications for laparoscopic resection particularly for larger tumours and with anatomical variations of the porta. Methods: As the initial step for a right hemihepatectomy the retrohepatic tunnel of Belghiti is developed and the caudate process divided as far superiorly as possible. Liver parenchyma is dissected away from the posterior aspect of the right hepatic inflow from medial to lateral, enabling safe stapling. Development of the retrohepatic tunnel and division of the posterior parenchyma is continued as the leading edge of the parenchymal transection, maintaining good surgical orientation especially for tumours close to the midline or cava. Similar concepts apply for a left hemihepatectomy, with dissection beginning in the in the Arantius groove. Results: 8 cases (6 right hemihepatectomy, 1 extended right hepatectomy, 1 extended left hepatectomy) have utilised this technique. I required conversion to a hybrid approach, and 1 case required transfusion. R0 resection was achieved in all cases. Average length of stay was 5 days. Comparison to 50 consecutive previous laparoscopic major hepatectomies demonstrates larger tumours and fewer conversions with the dorsal approach. Schematic and case videos will be presented. Conclusion: The dorsal approach to laparoscopic major hepatectomy is a novel technical variation that enables a safe, standardised technique and an expanded set of indications for a laparoscopic approach.