Totally Thoracoscopic Resection of Recurrent Intrahepatic Cholangiocarcinoma in Segment VII

Abstract

Introduction: With advancement in surgical techniques, minimally invasive techniques are increasingly being used for liver resection. Although most of the cases could be operated laparoscopically,1 there are few case reports and series describing thoracoscopic approach for liver tumors, especially those located in segment, VII, VIII, and IVa immediately under the diaphragm.2–5 Thoracoscopic approach can be especially useful in recurrent tumors located in posterosuperior segments as laparoscopic approach is more difficult and time consuming because of dense adhesions as seen in our case. Case Description: A 43-year-old woman underwent laparoscopic extended left hepatectomy, including segment, V, VIII, and XI with lymphadenectomy and was converted to open to perform biliobiliary anastomosis for intrahepatic cholangiocarcinoma in January 2014. Subsequently, four cycles of gemcitabine and oxaliplatin-based chemotherapy was administered. After chemotherapy, she developed a limited recurrence of 2.5 and 1.7 cm diameter at the cut surface of the liver treated with laparoscopic metastasectomy in October 2014. Later in February 2016, she underwent thoracoscopic excision of pulmonary metastatic lesion in left superior lobe. Subsequently, she was detected to have a 4 × 3.5 × 3 cm recurrent tumor in segment VII just under the diaphragm. PET-CT did not reveal any other site of metastasis. She underwent thoracoscopic resection of the recurrent liver lesion in September 2016 (Video). The patient was placed in the 45° left lateral position under general anesthesia with double lumen endotracheal tube. First, diagnostic laparoscopy was performed to rule out peritoneal dissemination. Adhesions around the porta hepatis were dissected such that Pringle's maneuver could be applied if required during parenchymal transection. Subsequently thoracoscopic procedure was initiated by using two 12 mm and two 5 mm ports as shown in the video. The tumor was located by using the flexible laparoscopic ultrasound probe through the diaphragm; the diaphragm was opened immediately above the tumor using Thunderbeat® (Olympus, Tokyo, Japan). The diaphragm was separated from the tumor and the limits of liver resection were marked with the help of laparoscopic ultrasound. With the help of Gayet bipolar forceps (MicroFrance CEV134; Integra life) and Thunderbeat (Olympus), wide local excision of the tumor was performed as demonstrated in the video. The specimen was extracted using a retrieval bag by a separate incision between the vertebral ribs. After confirming hemostasis and biliostasis, the diaphragm was closed by continuous suturing using nonabsorbable V-LOC™ (Covidien). Results: The operative time was 180 minutes with blood loss of 150 mL. She had uneventful postoperative recovery and was discharged on postoperative day 4. Histopathology revealed recurrent intrahepatic cholangiocarcinoma with tumor-free resection margin and a small adjoining liver hemangioma as shown in the preoperative imaging. The patient received gemcitabine-based adjuvant chemotherapy after surgery. On the last follow-up at 1 year after surgery, she is doing well without any evidence of recurrence. Conclusion: Thoracoscopic approach could be an interesting alternative to abdominal approach for resection of liver lesions located under the diaphragm. No competing financial interests exist. Runtime of video: 5 mins 56 secs Presented at the AP-HPBA, in Tokyo, June 9, 2017.