The “Dorsal” approach to laparoscopic major hepatectomy

Abstract

This new technique is a modification of the caudal approach of Soubrane. After a long experience of over 600 laparoscopic hepatectomies, this posterior to anterior procedure has enabled us to perform major hepatectomy more easily, via a standardised technique, for larger tumours, and for anatomical variations of the porta. 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. A small hepatotomy anterior to the right inflow then allows stapling of the right hepatic inflow without blind force or risk of compromise to the confluence. Development of the retrohepatic tunnel and division of the posterior parenchyma is continued as the leading edge of the parenchymal transection, with subsequent division of the anterior parenchyma. This maintains good surgical orientation, especially for tumours close to the midline or cava, and for the middle hepatic vein. This also aids haemostasis by allowing the application of pressure in a postero-anterior direction. After completion of the parenchymal transection, the right hepatic vein is divided, followed by the hepatocaval ligament, accessory hepatic veins, and peritoneal attachments. The same concepts can be applied to left and extended left hepatectomy. This technique has enabled expanded indications for a laparoscopic approach to major hepatectomies as well as a standardized operative technique. Schematic and case videos will be presented.