Left Semilateral Position Research Articles

A case of laparoscopic hepatectomy for recurrent hepatocellular carcinoma after two previous open hepatectomies.

Introduction: Laparoscopic hepatectomy after open hepatectomy may be relatively easy depending on the positions of the tumor and the previous hepatectomy site. When adhesions are evident, however, laparotomy may be inevitable. We performed laparoscopic liver S5 partial resection for a patient with recurrent hepatocellular carcinoma(HCC) in S5 after having undergone open hepatectomy twice before and transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) multiple times during the previous 12 years. The video shows the procedure. Method: Patient: A man in his 70s. HPI: Liver S7 segmentectomy had been performed for HCC in 2006. HCC recurred in S1, and liver S1 partial resection was performed in 2009. Thereafter, TACE and RFA were performed four times each until 2018. The posterior branch of the portal vein was narrowed because of RFA. Hepatoma recurred at the inferior border of S5 of the liver in 2018. Laboratory data: HCV antibody positive, PLT 78,000/μl, ICGR15’ 18.0%. Result: Operative procedure: Left semi-lateral position. First, three ports were placed in the lower abdomen for adhesiolysis. After adhesiotomy of the greater omentum and the ascending colon was performed toward the liver, detachment of the descending part of the duodenum proceeded in a caudocranial direction. When the inferior surface of the liver was reached, the target liver tumor was confirmed with intraoperative ultrasonography. Several ports were added, and partial resection of S5 of the liver was performed. Conclusion: Even after two previous open hepatectomies, laparoscopic resection is possible, providing that preoperative image simulation and thorough adhesiotomy of the adjacent organs are performed, and laparoscopic resection should be attempted.

Robotic-assisted right posterior segmentectomies for liver lesions: single-center experience of an evolutional method in left semi-lateral position.

Despite the popularity of minimally invasive surgery (MIS) for hepatectomy, limitations in the approach of the right posterior section of the liver remain. Although skills and approach techniques have been developed for hepatectomy of lesions in the posterior segments of the liver, most are performed laparoscopically and are limited to few experienced hands using rigid laparoscopic instruments. In this study, we tried a different approach area via the aid of a flexible robotic system. Since 2012, we have successfully completed more than 200 robotic hepatectomy procedures in our institution. Two different patient settings have been applied for right posterior segment lesions, including supine position as general setting in early cases and left semi-lateral decubitus setting in our later cases. The demographic data and perioperative outcomes between the two groups were analyzed in regard to different positioning. A total of 25 patients with right posterior segment lesions underwent robotic-assisted resection, 13 were placed in supine position and 12 in left semi-lateral position. The left semi-lateral group had significantly shorter operation time (306.0 versus 416.8min, p = 0.023), less blood loss (203.9 versus 1092.3mL, p = 0.030), and lower transfusion rates (0 versus 46.2%, p = 0.015). We described an evolutionary technique for robotic right posterior segmentectomies with the patient placed in left semi-lateral position. This method can be applied for most patients easily and is demonstrated as a safe and feasible approach in selected patients owing to its ability to overcome the difficulty of MIS hepatectomy for right posterior lesions.

Successful resection of a massive mediastinal liposarcoma that rapidly extended into the entire left thoracic cavity: report of a case

Primary mediastinal liposarcomas are rare malignancies, comprising fewer than 1% of all mediastinal tumors. We herein report a radical resection of a massive liposarcoma arising from the anterior mediastinum. A 63-year-old male patient presented with a 4-week history of dyspnea that had worsened over the previous several days. The patient had also experienced hoarseness for 2 weeks. Chest X-ray and computed tomography revealed a huge tumor occupying the entire left thoracic cavity. Anesthesia was induced when the patient was in the left semilateral position. The patient was moved into the right lateral position after initially stabilizing anesthesia with separate lung ventilation. The fourth rib was initially resected for thoracotomy, but there was no clearance between the tumor and the adjacent mediastinal structures, and two more ribs were therefore removed. The tumor had not invaded the other structures such as the chest wall, lung, or mediastinum. To reduce the tumor blood flow, the left internal mammary artery was ligated before the tumor was resected en bloc. The tumor was diagnosed as a liposarcoma arising from the thymus. The patient remains alive with no evidence of disease recurrence at 22 months after the operation.

A novel laparoscopic approach to lesions related to the posterior aspect of the pancreatic head

The posterior aspect of the pancreatic head has proven to be a technically demanding region to approach laparoscopically. Previously, this region was approached through the gastrocolic ligament with the patient in a left semilateral position. We believe that this makes the laparoscopic approach to the posterior pancreatic head extremely difficult. In the technique presented here, which has been successfully used in 4 patients, the patient was in full left lateral position, and Nathanson retractors were used to retract the liver and right kidney. This allowed full exposure of the second part of the duodenum before any major dissection. The duodenum was then Kocherized, and the posterior aspect of the pancreatic head, along with the inferior vena cava, left renal vein, and aorta, was exposed. We describe here a safe and feasible laparoscopic method for access to and management of lesions related to the posterior aspect of the pancreatic head.

Laparoscopy-assisted right hepatic lobectomy using a wall-lifting procedure

This article describes a new technique for performing a laparoscopy-assisted right hepatic lobectomy using a hanger wall-lifting procedure. The patient is placed in the left semi-lateral position. A cholecystectomy and hemi-hepatic vascular inflow control are then performed through a midline incision, through which the resected liver can be removed. Next, the right lower chest and right upper abdominal wall are lifted by two wires vertical to the abdominal wall. Two ports, a 5-mm port in right lateral abdomen for forceps and a 12-mm port just right of the umbilicus for the laparoscope, are inserted. The obtained view of the operative field in the right upper abdominal cavity is thus excellent. The laparoscopy-assisted mobilization of the right hepatic lobe is done with the assistance of a hand inserted through the midline incision, including a dissection of the hepato-renal ligament, the right triangular ligament, and the right coronary ligament. A parenchymal dissection is then performed using the Cavitron Ultrasonic Surgical Aspirator (CUSA) and the resected specimen is passed through the midline incision without any morcellation of the liver. This procedure can minimize the length of the wound, while avoiding the lethal complications associated with pneumoperitoneum.

Novel System for Complete Removal of Secretions within the Endotracheal Tube

Novel System for Complete Removal of Secretions within the Endotracheal Tube

Fiberoptic Orotracheal Intubation in the Left Semilateral Position

To the Editor: Endotracheal intubation in the left lateral position is still recommended by some authorities (1,2). The left lateral position prevents the laryngeal structure from collapsing, and this position is recommended in adult basic life support (3). We assessed the usefulness of semilateral positioning for visualizing the larynx during fiberoptic orotracheal intubation. After obtaining approval from the Division Ethics Committee of the IRB and written informed consent, 50 scheduled surgical patients were studied. After inducting anesthesia and confirming adequate mask ventilation, we inserted the fiberoptic bronchoscope (FOB) into the patient’s larynx in the common supine position without assistance, in the supine position with assistance that consisted of holding the lower jaw upward, and in the left semilateral position using a soft pillow under the right side of the back and rotating the head of the patient naturally to the left (Fig. 1). The degree of visualization of the laryngeal structure was evaluated using the classification of Aoyama et al. (4). In the supine position, visualizing the glottis through the FOB was impossible in 44 patients (88%) (Table 1), whereas visualizing the glottis was easy in 41 patients (82%) in the semilateral position.Figure 1: A view of the left semilateral position immediately before intubation. The patient’s neck naturally turns to the left and the fiberoptic bronchoscope is inserted through the mouth. The patient was Yushi U. Adachi, MD himself during induction of anesthesia for neurinoma surgery.Table 1: Visualization for Laryngeal Structure in Three PositionsDimitriou and Voyagis (5) reported a light-guided intubating technique with patients lying in the lateral position. We used only “semilateral” positioning in each patient; however, we never anticipated the quality of the view that could be acquired in this position. Although the FOB is a powerful tool for difficult intubation, the most important factor is obtaining an optimal view (6). Left semilateral positioning using only a soft pillow produced a sufficiently good view of laryngeal structure using a FOB without an assistant (7) or special devices (4). Yushi U. Adachi, MD Maiko Satomoto, MD Hideyuki Higuchi, MD, PhD

Successful cardiopulmonary resuscitation of a parturient with amniotic fluid embolism

A case of presumed amniotic fluid embolism is presented. Diagnosis is based on clinical findings in a 21-year-old parturient, who was admitted to hospital at 39 weeks gestation. During labor the patient became dyspneic and cyanotic, had convulsions and finally suffered a cardiac arrest. During cardiopulmonary resuscitation she was placed in a left semilateral position and an emergency cesarean section was performed immediately. Following delivery of the baby the heart rhythm returned to normal. The prolonged resuscitation produced serious neurological sequelae in both mother and infant in the first few months following delivery, though with complete long-term recovery. This case report highlights the importance of displacing the uterus laterally and performing an emergency cesarean section during resuscitation.