Laparoscopic Left Hemihepatectomy Research Articles

Comparison of pure laparoscopic versus open left hemihepatectomy by multivariate analysis: A retrospective cohort study

Comparison of pure laparoscopic versus open left hemihepatectomy by multivariate analysis: A retrospective cohort study

Pure Laparoscopic Left Hemihepatectomy for Hepatic Peribiliary Cysts with Biliary Intraepithelial Neoplasia.

Introduction. Hepatic peribiliary cysts (HPCs) usually originate due to the cystic dilatation of the intrahepatic extramural peribiliary glands. We describe our rare experience of pure laparoscopic left hemihepatectomy (PLLH) in a patient with HPCs accompanied by a component of biliary intraepithelial neoplasia (BilIN). Case Presentation. A 65-year-old man was referred for further investigation of mild hepatic dysfunction. Contrast-enhanced computed tomography showed dilatation of the left-sided intrahepatic bile duct, and biliary cytology showed class III cells. The patient was highly suspected of having left side-dominated cholangiocarcinoma and underwent PLLH. Microscopic findings revealed multiple cystic dilatations of the extramural peribiliary glands; hence, this lesion was diagnosed as HPCs. The resected intrahepatic bile duct showed that the normal ductal lumen comprised low columnar epithelia; however, front formation on the BilIN was observed in some parts of the intrahepatic bile duct, indicating that the BilIN coexisted with HPCs. Conclusion. We chose surgical therapy for this patient owing to the presence of some features of biliary malignancy. We employed noble PLLH as a minimally invasive procedure for this patient.

Laparoscopic Left Hemihepatectomy for Left-sided Hepatolithiasis.

Hepatolithiasis is a prevalent disease in the southeastern coastal regions of China. Partial hepatectomy is the most definitive treatment for hepatolithiasis. This study evaluated the safety and efficacy of the laparoscopic left hemihepatectomy (LLH) for left-sided hepatolithiasis. The clinical data of 37 consecutive patients who underwent pure LLH for left-sided hepatolithiasis at Yinzhou Second Hospital between March 2009 and December 2013 were reviewed retrospectively. Pure LLH was performed successfully in 36 patients. Because of severe adhesions from previous choledochotomy, 1 patient was converted to open procedure. The mean operative time was 257.9 minutes (range, 188 to 396 min). The mean duration of postoperative hospital stay was 11.7 days (range, 8 to 21 d). There were 2 (5.4 %) cases of postoperative bile leakage, 2 (5.4%) cases of intra-abdominal fluid collection, and 1 (2.7%) case of incisional infection, which were successfully managed conservatively. Residual stones were observed in 2 (5.4%) patients. The residual stones were located in the common bile duct in these cases and were removed through the T-tube tract by choledochoscopy. During a mean follow-up of 31.3 months (range, 6 to 63 mo), recurrent stones were detected in 2 (5.4%) patients and were successfully treated with endoscopic sphincterotomy. LLH for left-sided hepatolithiasis is feasible and safe in selected patients.

Laparoscopic versus open left hemihepatectomy for hepatolithiasis

BackgroundPartial hepatectomy is the most definitive treatment for hepatolithiasis. Laparoscopic liver resection, however, presents unique technical challenges. The objectives of this study were to evaluate and compare the safety and perioperative and long-term outcomes of laparoscopic left hemihepatectomy (LLH) versus open left hemihepatectomy (OLH) for left intrahepatic duct stones. MethodsFrom March 2009–October 2014, 97 consecutive patients with left intrahepatic duct stones who underwent LLH (n = 46) or OLH (n = 51) were evaluated. We retrospectively reviewed the clinical outcomes and the stone clearance rates of the 97 patients in this study. ResultsThe median surgical procedure times were 254 min (188–396 min) in the LLH group and 236 min (192–395 min) in the OLH group. No significant difference was found in the surgical procedure times between the two groups. The intraoperative blood loss of the LLH group was less than the OLH group (332 mL [247–914 mL] versus 369 mL [221–996 mL], P = 0.13), but there was no statistical significance. A shorter length of postoperative hospital stay was noticed in laparoscopy group (11 d [8–21 d] versus 12 d [9–24 d], P = 0.01). Postoperative complications were observed in six of the 46 patients (13.0%) after LLH and in 11 of the 51 patients (21.6%) after OLH (P = 0.27). Laparoscopy was comparable with laparotomy in the effectiveness of stone clearance during the first attempt (93.5% versus 94.1%, P = 1.00). ConclusionsIn left-sided hepatolithiasis, LLH was safe and effective: it resulted in low postoperative morbidity, no mortality, and a high stone clearance rate. The potential benefit of LLH was a shorter hospital stay. If consideration is given to the appropriate indication criteria, including the extent of hepatectomy and the location and distribution of lesions, LLH may be an excellent choice for treatment of left-sided hepatolithiasis.

Clinical efficacy of laparoscopic anatomical hepatectomy via Glissonean pedicle transection approach

Objective To investigate the clinical efficacy of laparoscopic anatomical hepatectomy via Glissonean pedicle transection approach. Methods The clinical data of 68 patients who underwent laparoscopic anatomical hepatectomy by Glissonean pedicle transection approach at the Southwest Hospital of Third Military Medical University between March 2009 and December 2013 were retrospectively analyzed. All the patients received intravenous-inhalation general anesthesia. The splitting of liver was carried out after Glissonean pedicles were completely dissected and occluded under the laparoscope according to anatomical structure. The patients with hepatolithiasis underwent intraoperative bile duct exploration and stone removal with T-tube placement based on the conditions of extrahepatic biliary lesions. The fragmented specimens from benign lesions of liver were taken out through a Trocar hole with the diameter of 12mm. The complete specimens from malignancy tumors of liver were taken out through an enlarged Trocar hole or transverse incision at the symphysis pubis. According to the recheck results of benign and malignancy lesions, the patients were followed up by outpatient examination and telephone interview till September 2014. The measurement data with normal distribution were presented as ±s. The survival curve was drawn by Kaplan-Meier method. Results Among the 68 patients, laparoscopic anatomical hepatectomy via Glissonean pedicle transection approach was performed on 64 patients and 4 patients were coverted to open surgery. Laparoscopic anatomical left hemihepatectomy was performed on 30 patients, anatomical right hemihepatectomy on 19 patients, anatomical right posterior lobectomy on 10 patients and anatomical right anterior lobectomy on 9 patients. The mean operation time, volume of intraoperative blood loss, rate of perioperative blood transfusion, time of postoperative gastrointestinal function recovery and duration of hospital stay were (224±117) minutes, (413±349) mL, 5. 9% (4/ 68) , (3. 0±0. 5) days and (8. 0±3. 0) days, respectively. There was no perioperative death, and 6 patients with postoperative complication were cured by symptomatic treatment. The tumor diameter and distance to resection margin in 29 patients with malignancy tumors of liver were (4. 4 ± 1.6) cm and (2. 0±0.9) cm, respectively. The results of pathological examination showed that hepatolithiasis was detected in 22 patients, cavernous hemangioma of liver in 12 patients, hepatic focal nodular hyperplasia in 1 patient, hepatic adenoma in 1 patient, hepatic angiomyolipoma in 1 patient, hepatic multiple cysts in 1 patient, hepatic tuberculosis in 1 patient, hepatocellular carcinoma in 27 patients and cholangiocarcinoma in 2 patients. All the 68 patients were followed up for 6-60 months with a mean time of 24 months. No recurrence and residual stones or lesions in 39 patients with benign lesions of liver were detected during the follow-up. The 1-, 3-, 5-year overall survival rates and tumor-free survival rates in 29 patients with malignant tumors of liver were 92% , 84% , 60% and 83% , 59% , 42% , respectively. Conclusion Laparoscopic anatomical hepatectomy via Glissonean pedicle transection approach is safe and feasible, and is suitable not only for left hemihepatectomy, but also for right hemihepatectomy of high technical specification. Key words: Liver neoplasms; Hepatolithiasis; Laparoscopy; Hepatectomy; Glissonean pedicle

Clinical efficacy of laparoscopic left hemihepatectomy for the treatment of intrahepatic bile duct stones

Objective To explore the clinical efficacy of laparoscopic left hemihepatectomy for the treatment of intrahepatic bile duct stones. Methods The clinical data of 30 patients with left intrahepatic bile duct stones who were admitted to the Second Affiliated Hospital of Nanchang University from June 2013 to June 2014 were retrospectively analyzed. All the patients underwent laparoscopic left hemihepatectomy by the Glisson intra- and extrapedicles vascular inflow occlusion techniques together with the removal of choledocholithiasis and right bile duct stones, and T tube placement or laparoscopic primary suture of common bile duct were selected according to the condition of bile duct. All the 30 patients were readmitted to hospital and detected by color Doppler ultrasound (CDUS) , computed tomography (CT) and T tube cholangiography at postoperative month 1, and then received CDUS reexamination every 3 months. CT and MRI reexaminations were applied to patients with complication of residual stones if necessary. All the patients were followed up till July 2014. Results All the 30 patients were treated by laparoscopic hepatectomy with left hemihepatic vascular inflow occlusion, including 5 with conversion to open surgery and 25 with successful operation. The Glisson extra- and intra-pedicel vascular inflow occlusion techniques were used in 11 and 14 patients, respectively. The operation time and volume of blood loss were (158 ±85) minutes and (405 ±215) mL. Two patients received intraoperative blood transfusion. There were no residual stones in the 8 patients with choledocholithiasis by intraoperative choledochoscope, and primary suture of bile duct and T tube placement were done in 5 and 3 patients, respectively. No patients died. After operation, there were 2 patients with bile leakage and 1 with pleural effusion, and they were cured though drainage. One patient with subphrenic effusion was cured by B ultrasound-guided puncture and drainage. One patient had bleeding with the volume of blood loss of 500 mL, and was cured by conservative treatment. The duration of hospital stay in all the patients was (8. 5 ±2. 3) days. No bile leakage and abdomen infection were detected by outpatient examination. The time of follow-up was 1-12 months, without recurrence of stones. Conclusion Laparoscopic left hemihepatectomy for the treatment of left intrahepatic bile duct stones is safe and feasible with satisfactory outcome. Key words: Cholelithiasis; Laparoscopy; Hepatectomy

Laparoscopic Left Hemihepatectomy for Treatment of Left Intrahepatic Duct Stones

Laparoscopic Left Hemihepatectomy for Treatment of Left Intrahepatic Duct Stones

Laparoscopic liver resection and the learning curve: a 14-year, single-center experience

Laparoscopic liver resection has not been widely used because of intraoperative bleeding. This problem should be solved with instruments and techniques that require a short learning curve. The aim of this work was to present the technique used in our center to perform laparoscopic liver resection using the 'curettage and aspiration' technique with laparoscopic Peng's multifunctional operational dissectors and regional occlusion of inflow and outflow. We retrospectively analyzed patients who underwent a laparoscopic liver resection from August 1998 to August 2012, and collected the conversion rate, operating time, blood loss, hospitalization, bile leakage rate, bleeding rate, and other complications on a yearly basis and in total. We used SPSS software to analyze whether there was a significant difference, and summarized the learning curve of laparoscopic liver resection with various procedures. We performed 365 cases of laparoscopic liver resection, including left hemihepatectomy, left lateral lobectomy, segmental hepatectomy, non-anatomic liver resection, right hemihepatectomy, and caudate lobectomy. The diseases included liver cancer, hepatolithiasis, liver hemangioma, focal nodular hyperplasia, liver abscess, and metastatic hepatic carcinoma. In total, 63 cases (17.20 %) were converted to open surgery because of severe adhesions, bleeding, or anatomical limitation. Mean blood loss was 370.6 ± 404.0 ml; mean operating time was 150.8 ± 73.0 min; and mean postoperation hospitalization was 9.2 ± 5.3 days. There were four cases (1.32 %) with the complication of bile leakage and two cases of hemorrhage (0.66 %). No intraoperative or postoperative deaths occurred. After finishing 15-30, 43, 35, and 28 cases of laparoscopic left hemihepatectomy, left lateral hepatectomy, non-anatomic liver resection, and segmentectomy, respectively, the average operating time, blood loss, and hospitalization were almost the same as the overall mean results. The technique used in our center is a safe, fast, and effective approach to laparoscopic liver resection. Our 14 years of experience demonstrates that this technique can prevent postoperative bleeding and bile leakage. A surgeon can master the skill of laparoscopic left hemihepatectomy, left lateral hepatectomy, non-anatomic liver resection, and segmentectomy after ∼15-30, 43, 35, and 28 case procedures, respectively.

Comparison of Laparoscopic Versus Open Left Hemihepatectomy for Left-Sided Hepatolithiasis

PURPOSE: The purpose of this study was to evaluate and compare the perioperative and long-term outcomes of open versus laparoscopic left hemihepatectomy (OLH vs. LLH) for left-sided hepatolithiasis.METHODS: Between October 2007 and June 2012, 149 patients with left-sided hepatolithiasis who underwent LLH (n = 37) or OLH (n = 112) were evaluated. The perioperative and long-term outcomes that were reviewed included the stone clearance rate, operative morbidity and mortality, and the stone recurrence rate.RESULTS: The mean operative time of the LLH group was significantly longer than that of the OLH group (257±50.4 minutes vs. 237±75.5 minutes, p = 0.022), but the mean hospital stay was significantly shorter (8.8±4.10 vs. 14.1±4.98 days, p < 0.001). Postoperative complications were noted in four and twenty cases among LLH and OLH patients, respectively (p = 0.982). The initial clearance rate of intrahepatic duct (IHD) stones was 100% and 96.4% in the LLH and OLH groups, respectively, but all remnant stones (n = 4, OLH group) were resolved postoperatively. There were two cases of recurrence of IHD stones in OLH patients, but none in LLH patients (p = 0.281).CONCLUSIONS: In left-sided hepatolithiasis, LLH was safe and effective: it resulted in low postoperative morbidity, no mortality and a high stone clearance rate, and there were no incidences of recurrence in our study. The potential benefits of LLH include a shorter hospital stay and a faster return to oral intake. If consideration is given to the appropriate indication criteria, including the extent of hepatectomy and the location and distribution of lesions, LLH may be an excellent choice for treatment of left-sided hepatolithiasis.

Lithotomy Using Cholangioscopy via the Left Hepatic Duct Orifice Versus the Common Bile Duct in Laparoscopic Treatment of Left-Sided Hepatolithiasis: A Comparative Study

Laparoscopic hepatectomy is widely used in the surgical treatment of left-sided hepatolithiasis (LSH). Lithotomy using a cholangioscope usually is required for the treatment of concurrent right-sided hepatolithiasis or choledocholithiasis. The primary objective of this study was to evaluate the effectiveness and safety of gallstone elimination using cholangioscopy through the left hepatic duct (LHD) orifice versus the common bile duct (CBD). Eligible LSH patients (n=41) were scheduled for laparoscopic left lateral segmentectomy or left hemihepatectomy with intraoperative biliary exploration using cholangioscopy through the LHD orifice (LHD group, n=23) or the CBD (CBD group, n=18) at the discretion of patients. Laparoscopic T-tube insertion was performed in selected patients. Patients were regularly followed up at monthly intervals or more frequently in the presence of any symptom. The primary outcome measures included overall operative time, duration of the cholangioscopy procedure, volume of blood loss, length of hospital stay, and frequency of procedure-related complications. The two groups were comparable in sex, age, symptoms, site of lesion, and gallstone comorbidities (P>.05). Of the 18 patients in the CBD group, 12 (66.7%) patients had a T-tube inserted in contrast to 1 (4.5%) patient in the LHD group. The two groups were comparable in cholangioscopy duration and volume of blood loss (P>.05), whereas the LHD group had a significantly shorter operative time than the CBD group (221.4 ± 58.6 minutes versus 171.2 ± 63.5 minutes; P<.05). The postoperative duration of hospitalization was significantly shorter in the LHD group than in the CBD group (7.5 ± 2.2 days versus 4.2 ± 1.9 days; P<.05). No patient showed any recurrence of gallstones or cholangitis during the follow-up period. As an effective and safe technique that is comparable to choledochotomy, LHD cholangioscopy is a preferred alternative to choledochotomy in the laparoscopic treatment of LSH because it offers patients shorter operative duration and length of hospitalization.

Laparoscopic left hemihepatectomy a consideration for acceptance as standard of care

Since the inception of laparoscopic liver surgery, the left-lateral sectionectomy has become the standard of care for resection of lesions located in segments II and III. However, few centers employee laparoscopic left hemihepatectomy on a routine basis. This study evaluated the safety and efficacy of the laparoscopic left hemihepatectomy as a standard of care. An international database of 1,620 laparoscopic liver resections was established and outcomes analyzed comparing the laparoscopic left lateral sectionectomy (L lat) to laparoscopic left hemihepatectomy (LH). All data are presented as mean ± standard deviation. A total of 222 laparoscopic L lat and 82 LH were identified. The L lat group compared with LH group had a higher incidence of cirrhosis (27 vs. 21 %; p = 0.003) and cancer (48 vs. 35 %; p = 0.043). Tumors were larger in the LH group (7.09 ± 4.2 vs. 4.89 ± 3.1 cm; p = 0.001). Operating time for LH was longer than L lat (3.9 ± 2.3 vs. 2.9 ± 1.4 h; p < 0.001). Operative blood loss was higher in LH (306 vs. 198 cc; p = 0.003). Patient morbidity (20 vs. 18 %; p = 0.765) was equivalent with a longer length of stay (7.1 ± 5.1 vs. 2.5 ± 2.3 days; p < 0.001) for LH. Patient mortality and tumor recurrence were equivalent. Laparoscopic left hemihepatectomy is a more technically challenging and often time-consuming procedure than a left-lateral sectionectomy. This international multi-institutional confirmed that intraoperative blood loss, complications, and conversions are more than acceptable for laparoscopic left hemihepatectomy in expert hands. Postoperative morbidity and mortality rates together with adequate surgical margins and long-term recurrence are not compromised by the laparoscopic approach.

Arantius’ ligament approach for the left extrahepatic Glissonean pedicle in pure laparoscopic left hemihepatectomy

Laparoscopic hemihepatectomy has not yet become widely accepted because of the technical difficulties in controlling each Glissonean pedicle laparoscopically. The subjects in the present study included 12 patients who underwent laparoscopic left hemihepatectomy between August 2007 and June 2011. Arantius' ligament was divided. Retracting the caudal stump of the ligament revealed a space between the left Glissonean pedicle and the liver parenchyma. The left Glissonean pedicle could be easily encircled by using an Endo Retract Maxi. No Glissonean injuries, including bleeding or biliary leakage, occurred in any of the 12 patients. Therefore, the Arantius' ligament approach for the left extrahepatic Glissonean pedicle appears to be feasible and safe for successfully performing pure laparoscopic left hemihepatectomy.

Effect of Selective Inflow Occlusion on Hemodynamic Conditions during Laparoscopic Left Hemihepatectomy

Selective inflow occlusion instead of portal triad clamping was used during laparoscopic left hemihepatectomy in our institution. This study observed its hemodynamic effects during operation. Hemodynamic parameters including heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), mean pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR) were collected at 6 time points: after induction, after insufflation with CO2, after patient in reverse Trendelenburg position, after left branch of hepatic artery was occluded, after left branch of portal vein was occluded and after desufflation with patient supine. No severe perioperative cardiopulmonary complications were observed. Occlusion of left branch of hepatic artery brought no significant hemodynamic change. Occlusion of left branch of portal vein increased CVP and CI and decreased SVR. CO2 inflation caused HR, MAP and SVR to increase. The change to reverse Trendelenburg position caused CVP and PAP to decrease. When placed in the supine position with deflation, MAP, CVP, PAP, PCWP and CI went to a higher than base level. HR and SVR returned to base level. Using selective inflow occlusion in laparoscopic left hemihepatectomy caused few hemodynamic changes before and after occlusion in patients without cardiopulmonary diseases. However, the change of position and inflation or deflation caused significant changes.

Laparoscopic left hemihepatectomy for left intrahepatic duct stones

PurposeThe feasibility of laparoscopic left hemihepatectomy for the management of intrahepatic duct (IHD) stones was evaluated.MethodsThe clinical data of 26 consecutive patients who underwent total laparoscopic left hemihepatectomy for IHD stones at Gyeongsang National University Hospital between January 2009 and June 2011 were reviewed retrospectively.ResultsThe mean operation time was 312.1 ± 63.4 minutes and the mean postoperative hospital stay was 11.8 ± 5.0 days. There were 2 cases of postoperative bile leakage and 3 cases of intra-abdominal fluid collection, which were successfully managed conservatively. Remnant stones were detected in 2 patients. The initial success rate of stone clearance was 92.3% (24 of 26). The remnant stones were located in the common bile duct in both cases and were removed by endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy. Therefore, the final success rate of stone clearance was 100% (26 of 26). During a mean follow-up of 22 months (range, 7 to 36 months), there was no patient with recurrent stone.ConclusionLaparoscopic surgery could be an effective treatment modality for the management of IHD stones in select patients.

Pure Laparoscopic En Bloc Left Hemihepatectomy and Caudate Lobe Resection in Patients with Intrahepatic Cholangiocarcinoma

There is an ongoing debate on whether it is safe to push the boundaries and widen the indications of laparoscopic liver surgery after careful patient selection. We report 2 cases of pure laparoscopic en bloc left hemihepatectomy and caudate lobe resection for intrahepatic cholangiocarcinoma (ICC). The first patient (a 79-year old) had an ICC affecting segments 2, 3, and 4 of the liver with dilatation of segment 1 ducts at preoperative imaging. The second patient (an 81-year old) had an ICC affecting segments 2, 3 with local invasion of segment 1. Both patients underwent pure laparoscopic left hemihepatectomy and caudate lobe resection. The first patient's operative time was 360 minutes and blood loss was 390 mL. Postoperative hospital stay was 8 days. The definitive histology was as follows: pT1 ICC (25 mm in maximal diameter), with 20 mm free resection margin. The second patient's operative time was 310 minutes and blood loss was 300 mL. Postoperative hospital stay was 4 days. The definitive histology was as follows: T1 ICC (49 mm in maximal diameter) with 10 mm free resection margin. The first patient was disease free 12 months after surgery. The second patient died 11 months after surgery of metastatic disease. Pure laparoscopic left hemihepatectomy and caudate lobectomy for ICC may be feasible and safe. This is, however, a very complex procedure requiring extensive experience in laparoscopic liver surgery and careful patient selection to optimize surgical outcome. To our knowledge, this is the first systematic description of a pure laparoscopic en bloc left hemihepatectomy and caudate lobe resection for ICC.

Intrahepatic Glissonian Approach for Pure Laparoscopic Left Hemihepatectomy

Recent advances in laparoscopic devices and experience with advanced techniques have increased the indications for laparoscopic liver. The aim of this work was to present a video with technical aspects of a pure laparoscopic left hemihepatectomy (segments 2, 3, and 4) by using the intrahepatic Glissonian approach and control of venous outflow without hilar dissection or the Pringle maneuver. A 63-year-old woman with a 5-cm solitary liver metastasis was referred for treatment. Four trocars were used. The left lobe was pulled upward and the lesser omentum was divided, exposing Arantius' ligament. This ligament is a useful landmark for the identification of the main left Glissonian pedicle. A small anterior incision was made in front of the hilum, and a large clamp was introduced behind the Arantius' ligament toward the anterior incision, allowing control of the left main sheath. Ischemic discoloration of the left liver was achieved and marked with cautery. The vascular clamp was replaced by a stapler. If ischemic delineation was coincident with a previously marked area, the stapler was fired. The left hepatic vein was dissected and encircled. Parenchymal transection and vascular control of the hepatic veins were accomplished with a Harmonic scalpel and an endoscopic stapling device, as appropriate. All these steps were performed without the Pringle maneuver and without hand assistance. Operative time was 220 minutes with minimum blood loss. Hospital stay was 4 days. Pathology showed free surgical margins. The patient is alive with no signs of recurrence 18 months after the operation. Totally laparoscopic left hemihepatectomy is safe and feasible in selected patients and should be considered for patients with benign or malignant liver neoplasms. The described technique, with the use of the intrahepatic Glissonian approach and control of venous outflow, may facilitate laparoscopic left hemihepatectomy by reducing the technical difficulties in pedicle control and may decrease bleeding during liver transection.

Totally Laparoscopic Left Hemihepatectomy Using Ventral Hilum Exposure (VHE) for Intrahepatic Bile Duct Stone

The unique technique of ventral hilum exposure (VHE) was reported that it had excellent surgical outcomes in patients with intrahepatic bile duct stone. The basis of this surgical technique is that all the openings of the 2nd-order bile duct branches are exposed fully. In this article, we describe laparoscopic hemihepatectomy from using the VHE method in a patient with intrahepatic bile duct stone. Our patient was a 70-year-old female who had been diagnosed with an intrahepatic duct stone 30 years prior. Multiple intrahepatic bile duct stones in the left lateral section of the liver were revealed by abdominal computed tomography and magnetic resonance cholangiopancreatography. The patient resumed her oral intake on postoperative day 6. The patient had hyperbilirubinemia (10.3 mg/100 mL) on postoperative day 10. However, her serum bilirubin level decreased to 2.7 mg/100 mL on postoperative day 28. She was discharged without any serious complications on postoperative day 31. Totally laparoscopic left hemihepatectomy, using the VHE method, can be one option of surgical procedure in the near future, although a larger series of cases should be necessary to prove the feasibility of laparoscopic VHE.

Laparoscopic left hemihepatectomy: a safety and feasibility study of 19 cases

Laparoscopic liver resection was performed at some institutes. The procedure mainly included local resection, segmentectomy, and left lateral segmentectomy. With experience accumulation and technique innovation, laparoscopic left hemihepatectomy was performed in selected patients. This study was designed to introduce and evaluate the safety and feasibility of this procedure. Nineteen successive patients underwent laparoscopic left hemihepatectomy from 2005 to 2007. They were compared by the matched-pair method with 19 other patients who underwent conventional open left hemihepatectomy. Surgical feature, postoperative course, and the learning curve of laparoscopic left hemihepatectomy were studied. Laparoscopic hemihepatectomy was successfully performed in 17 cases. Two conversions were required. Compared with the open group, the blood loss was significantly less in the laparoscopic group (462 +/- 372 vs. 895 +/- 704, p = 0.03). Postoperative hospital stay of the laparoscopic group was shorter but not significant compared with the open group (9 +/- 5 vs. 13 +/- 7, p = 0.086). Postoperative albumin level in the laparoscopic group was significantly higher than the open group (33 +/- 4.8 vs. 27.6 +/- 3.2, p = 0.001). There was no perioperative mortality in either group. Two complications occurred in the laparoscopic group (11%) and four in the open group (21%). A tendency of gradually decreased transecting time was noticed in the early cases (R(2) = 0.676; p = 0.012). Laparoscopic left hemihepatectomy is a safe and feasible procedure for select patients.

Laparoscopic resection of left liver segments using the intrahepatic Glissonian approach

Recent advances in laparoscopic techniques have resulted in growing indications for laparoscopic hepatectomy. However, this procedure has not been widely developed, and anatomic segmental liver resection is not currently performed due to difficulty controlling the segmental Glissonian pedicles laparoscopically. This study aimed to report a novel technique for laparoscopic anatomic resection of left liver segments using the intrahepatic Glissonian approach based on small incisions according to anatomic landmarks such as Arantius' and round ligaments. Nine consecutive patients underwent laparoscopic liver resection using the intrahepatic Glissonian technique from April 2007 to June 2008. Five patients underwent laparoscopic bisegmentectomy 2-3, one laparoscopic left hemihepatectomy, two resections of segment 3, and one resection of segment 4. One patient required a blood transfusion. The mean operation time was 180 min (range, 120-300 min), and the median hospital stay was 3 days (range, 1-5 days). No patient had postoperative signs of liver failure or bile leakage. No postoperative mortality was observed. The main advantage of the intrahepatic Glissonian procedure over other techniques is the possibility of gaining a rapid and precise access to the left Glissonian sheaths facilitating left hemihepatectomy, bisegmentectomy 2-3, and individual resections of segments 2, 3, and 4. The authors believe that the intrahepatic Glissonian technique facilitates laparoscopic liver resection and may increase the development of segment-based laparoscopic liver resection.

Laparoscopically Assisted Extrahepatic Cyst Excision and Left Hemihepatectomy for a Type IV-A Choledochal Cyst

Some studies have reported on laparoscopic excision for treating the choledochal cyst, yet there are no reports on laparoscopic surgery for treating type IV-A choledochal cysts that require a liver resection. In this paper, we report on a case of laparoscopic cyst excision combined with left hemihepatectomy and laparoscopy-assisted Roux-en-Y hepaticojejunostomy for treating a type IV-A choledochal cyst. A 51-year-old female was admitted with symptoms of jaundice and cholangitis. Percutaneous transhepatic biliary drainage (PTBD) was done preoperatively for controlling the cholangitis. The imaging studies revealed a type IV-A choledochal cyst with an associated stricture of the left main intrahepatic duct. After the resolution of the cholangitis, total laparoscopic cyst excision and left hemihepatectomy were performed by using the four-port technique, and then a Roux-en-Y hepaticojejunostomy was done by a laparoscopy-assisted method. The total operation time was 420 minutes. The estimated blood loss was 300 mL, and no perioperative transfusion was needed. The tubogram, which was performed through the PTBD on postoperative day 5, showed good patency of the bilioenteric anastomosis and no biliary leakage. The patient was discharged at postoperative day 7 without any complications. This case shows the feasibility of performing laparoscopic surgery for treating a type IV-A choledochal cyst that requires a liver resection. We believe that laparoscopic cyst excision with a liver resection can be one of the treatment options for selected patients with type IV-A choledochal cysts.