The Dorsal Approach to Laparoscopic Major Hepatectomy

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: 31 major resections (23 right +/- extended, 8 left +/- extended) have utilised this technique. 2 required conversion, and 1 required transfusion. R0 resection was achieved in 29 cases. Median hospital stay was 6 days. With this technique conversion rate has decreased from 29% to 6% (P = 0.032) and selection of a laparoscopic approach for major resections increased from 24% to 60% (P < 0.001). 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.