Posterior Sectionectomy Research Articles

Defining Global Benchmarks for Laparoscopic Right Posterior Sectionectomy/H67

Objective: We aimed to establish global benchmark outcomes indicators for L-RPS/H67. Background: Minimally invasive liver resections has seen an increase in uptake in recent years. Over time, challenging procedures as laparoscopic right posterior sectionectomies (L-RPS)/H67 are also increasingly adopted. Methods: This is a post hoc analysis of a multicenter database of 854 patients undergoing minimally invasive RPS (MI-RPS) in 57 international centers in 4 continents between 2015 and 2021. There were 651 pure L-RPS and 160 robotic RPS (R-RPS). Sixteen outcome indicators of low-risk L-RPS cases were selected to establish benchmark cutoffs. The 75th percentile of individual center medians for a given outcome indicator was set as the benchmark cutoff Results: There were 573 L-RPS/H67 performed in 43 expert centers, of which 254 L-RPS/H67 (44.3%) cases qualified as low risk benchmark cases. The benchmark outcomes established for operation time, open conversion rate, blood loss ≥500 mL, blood transfusion rate, postoperative morbidity, major morbidity, 90-day mortality and textbook outcome after L-RPS were 350.8 minutes, 12.5%, 53.8%, 22.9%, 23.8%, 2.8%, 0% and 4% respectively. Conclusions: The present study established the first global benchmark values for L-RPS/H6/7. The benchmark provided an up-to-date reference of best achievable outcomes for surgical auditing and benchmarking.

ASO Visual Abstract: Laparoscopic Right Posterior Sectionectomy with Preservation of Subsegment Using Augmented Reality Navigation Plus ICG Fluorescence Imaging in Patients with HCC After Conversion Therapy.

ASO Visual Abstract: Laparoscopic Right Posterior Sectionectomy with Preservation of Subsegment Using Augmented Reality Navigation Plus ICG Fluorescence Imaging in Patients with HCC After Conversion Therapy.

ASO Author Reflections: Laparoscopic Right Posterior Sectionectomy with Preservation of Subsegment Using Digital Intelligence Liver Surgery Technologies in Patients with HCC After Conversion Therapy.

ASO Author Reflections: Laparoscopic Right Posterior Sectionectomy with Preservation of Subsegment Using Digital Intelligence Liver Surgery Technologies in Patients with HCC After Conversion Therapy.

3D laparoscopic anatomical hepatectomy guided by 2D real-time indocyanine green fluorescence imaging for hepatocellular carcinoma.

Laparoscopic anatomical hepatectomy (LAH) for patients with hepatocellular carcinoma (HCC) has been advocated by many surgeons in the hope of producing better oncological outcomes. Two recent techniques, 3D laparoscopic system and 2D real-time indocyanine green fluorescence imaging (r-ICG) guidance, are benefit for improving the operative precision of LAH in different aspects. However, these two techniques cannot be applied concomitantly because of the technical limitation. Although a new modern laparoscopic system with both 3D and indocyanine green (ICG) imaging mode has been designed, it has not been listed in many countries including China. Thus, we design a new procedure to perform the 3D LAH with 2D r-ICG guidance for HCCs with conventional laparoscopic systems. In this procedure, both 3D and 2D laparoscopic systems were used. A total of 11 patients with HCC received 3D laparoscopic right posterior sectionectomy (LRPS) with 2D r-ICG guidance. The right posterior Glissonian pedicle was clamped under the 3D vision. Then ICG solution was then intravenously administrated. The liver parenchyma was transected under the 3D vision and guided by 2D ICG vision simultaneously. There was no severe complications (Clavien-Dindo ≥III) and operation related death. The 90-day mortality was also nil. By using this procedure, the advantages of two techniques, 3D laparoscopic system and 2D r-ICG guidance, were combined so that LAH could be performed with more precision. However, it should be validated in more studies.

Laparoscopic Right Posterior Sectionectomy with Preservation of Subsegment Using Augmented Reality Navigation Plus ICG Fluorescence Imaging in Patients with HCC After Conversion Therapy.

Laparoscopic Right Posterior Sectionectomy with Preservation of Subsegment Using Augmented Reality Navigation Plus ICG Fluorescence Imaging in Patients with HCC After Conversion Therapy.

Graft reduction in adult liver transplantation: indications, techniques, and outcomes

PurposeGraft reduction can be a patients and graft-saving option to avoid large-for-size syndrome. The aim of this article was to summarize the literature on graft reduction in adult liver transplantation and to show the technique of H 6/7 graft hepatectomy. MethodsThe technique, showed in a didactical video, entails an ex-situ posterior sectionectomy under hypothermic perfusion. The right hepatic vein is identified, and the transection line follows the right hepatic fissure. The Glissonean pedicles are ligated during parenchymal transection. ResultsA narrative review of the literature yielded seven studies. A total of 15 liver grafts were reduced in adult liver transplantations. Most of the reduction were ex situ (11/15; 73.3%); graft reduction entailed an H6,7 sectionectomy in 10 cases and one H2, 3 in one case. In-situ reduction included one right hepatectomy (H5, 6, 7,8), two H6, 7 sectionectomy, and one H2, 3 left lateral sectionectomy. The duration of ex-situ reduction averaged 56minutes (median 40.5minutes, range 33-130minutes), and the graft weight to recipient weight ratio (GWRW) decreased from 3.57±0.4 to 2.70±0.5% after graft reduction. The average cold ischemia time was 390minutes (range 230-570minutes). There were no liver retransplantations. ConclusionGraft reduction in adult liver transplantation can become necessary to avoid large-for-size syndrome. Ex-situ H6, 7 sectionectomy represents the easiest “graft reduction hepatectomy” and is able to minimize the occurrence of graft compression while leaving enough functional liver parenchyma.

Revisiting the Institut Mutualiste Montsouris Difficulty Classification of Laparoscopic Liver Resection with the Data from a Personal Series-Evaluations for the Difficulty of Left Medial Sectionectomy and Length of Hospital Stay.

The IMM (Institut Mutualiste Montsouris) difficulty classification for laparoscopic liver resection is based only on the type of surgical procedure. It is useful for assessing outcomes and setting benchmarks in a group sharing the same indications. There is, however, no left medial sectionectomy in the system. Its difficulty was evaluated using the same methodology as IMM with the data from a personal series. Furthermore, length of hospital stay was evaluated as the representative of short-term outcomes. IMM scores of our right and left hemihepatectomies, right anterior sectionectomy, and segment 7 or 8 segmentectomies are 3. That of left medial sectionectomies is 2, the same as right posterior sectionectomy and segment or less anatomical resections. Those of left lateral sectionectomy and partial resection are 0. The group with a score of 3 was divided into two groups-with and without extended hospital stays (extended only for right hemihepatectomies and right anterior sectionectomies). The difficulty of medial sectionectomy was positioned at the same level as posterior sectionectomy and segment or less anatomical resections. The result from the second evaluation may indicate that there are other factors with an impact on difficulty related to short-term outcomes, other than intraoperative surgical difficulty from the procedure itself.

ASO Author Reflections: How to Perform a Laparoscopic Right Posterior Sectionectomy with Glissonean Approach and Modified Hanging Maneuver, Guided by Indocyanine Green Fluorescence Imaging.

ASO Author Reflections: How to Perform a Laparoscopic Right Posterior Sectionectomy with Glissonean Approach and Modified Hanging Maneuver, Guided by Indocyanine Green Fluorescence Imaging.

Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique.

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver resections, including less blood loss, reduced wound pain, and shorter hospital stays with a comparable oncological outcome. However, laparoscopic resection of lesions in the right posterior section of the liver is challenging due to difficulties in bleeding control and visualizing the surgical field. In the past, laparoscopic right posterior sectionectomy (LRPS) was still in the exploration phase, with undefined risks in the Second International Consensus Conference on LLR in 2014. However, recent technological advancements and increased surgical experience have shown that LRPS can be safe and feasible. It has been found to reduce hospital stay and blood loss compared to open surgery. This manuscript aims to provide a detailed description of the steps involved in LRPS. The key factors contributing to our success in this challenging procedure include proper liver retraction and exposure, the use of an intrahepatic Glissonian approach for inflow control, a technique called the 'ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)' for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy.

Laparoscopic right posterior sectionectomy for a large hepatocellular carcinoma close to inferior vena cava.

Approximately 20% of hepatocellular carcinomas (HCC) occur in noncirrhotic livers. Resection may be considered for patients with HCC, provided sufficient future liver remnant is available, regardless of the tumor size. Tumors located posteriorly near the right hepatic vein (RHV), or inferior vena cava can be managed through anterior or caudal approaches. RHV is typically conserved during right posterior sectionectomy. When a large posteriorly placed tumor causes chronic compression on RHV, the right anterior section drainage is redirected preferentially to the middle hepatic vein. The division of RHV in such instances does not cause congestion of segments 8 and 5. The technical complexity of laparoscopic right posterior sectionectomy arises from the large transection surface, positioned horizontally. We describe in this multimedia article, a case of large HCC in segments 6 and 7, which was successfully treated using laparoscopic anatomic right posterior sectionectomy.

The Video Two of 3D laparoscopic right posterior sectionectomy guided by 2D real-time ICG fluorescence imaging.

The Video Two of 3D laparoscopic right posterior sectionectomy guided by 2D real-time ICG fluorescence imaging.

The Video One of 3D laparoscopic right posterior sectionectomy guided by 2D real-time ICG fluorescence imaging.

The Video One of 3D laparoscopic right posterior sectionectomy guided by 2D real-time ICG fluorescence imaging.

Risk factors of postoperative bile leakage after liver resection: A systematic review and meta-analysis.

Postoperative bile leakage (POBL) is one of the most common complications after liver resection. However, current studies on the risk factors for POBL and their impacts on surgical outcomes need to be more consistent. This study aims to conduct a meta-analysis to analyze the risk factors for POBL after hepatectomy. We incorporated all eligible studies from Embase, PubMed, and the Web of Science database (until July 2022) into this study. RevMan and STATA software were used to analyze the extracted data. A total of 39 studies, including 43,824 patients, were included in this meta-analysis. We found that gender, partial hepatectomy, repeat of hepatectomy, extended hepatectomy, abdominal drain, diabetes, Child≥B, solitary tumor, and chemotherapy are the factors of grade B and C POBL. Some recognized risk factors were considered potential risk factors for grade B and C bile leakage because no subgroup analysis was performed, like HCC, cholangiocarcinoma, major resection, posterior sectionectomy, bi-segmentectomy, S4 involved, S8 involved, central hepatectomy, and bile duct resection/reconstruction. Meanwhile, cirrhosis, benign diseases, left hepatectomy, and Segment 1 resection were not significant for grade B and C bile leakage. The influence of lateral sectionectomy, anterior sectionectomy, S1 involved, S3 involved, high-risk procedure, laparoscope, and blood loss>1000 mL on POBL of ISGLS needs further research. Meanwhile, POBL significantly influenced overall survival (OS) after liver resection. We identified several risk factors for POBL after hepatectomy, which could prompt the clinician to decrease POBL rates and make more beneficial decisions for patients who underwent the hepatectomy.

Comparison of pure laparoscopic donor right posterior sectionectomy versus right hemihepatectomy for living donor liver transplantation.

The right posterior section (RPS) graft for living donor liver transplantation is an alternative graft in a live liver donor with insufficient remnant left lobe volume and portal vein anomaly. Although there have been some reports regarding pure laparoscopic donor right posterior sectionectomy (PLDRPS), no study has compared PLDRPS versus pure laparoscopic donor right hemihepatectomy (PLDRH). The aim of our study was to compare the surgical outcomes of PLDRPS versus PLDRH at centers achieving a complete transition from open to laparoscopic approach in liver donor surgery. From March 2019 to March 2022, a total of 351 living donor liver transplantations, including 16 and 335 donors who underwent PLDRPS and PLDRH, respectively, were included in the study. In the donor cohort, there were no significant differences in major complication (≥grade III) rate and comprehensive complication index between the PLDRPS versus PLDRH group (6.3% vs. 4.8%; p = 0.556 and 2.7 ± 8.6 vs.1.7 ± 6.4; p = 0.553). In the recipient cohort, there was a significant difference in major complication (≥grade III) rate (62.5% vs. 35.2%; p = 0.034) but no significant difference in comprehensive complication index (18.3 ± 14.9 vs. 15.2 ± 24.9; p = 0.623) between the PLDRPS and PLDRH groups. PLDRPS in live liver donors with portal vein anomaly and insufficient left lobe was technically feasible and safe with experienced surgeons. The PLDRPS group might be comparable with the PLDRH group based on the surgical outcomes of donors and recipients. However, in terms of recipient outcomes, more careful selection of donors of the RPS graft and further research in a large number of cases are necessary to evaluate the usefulness of PLDRPS.

Surgical treatment of hepatocellular carcinoma after Fontan operation: three case reports and review of the literature.

We herein describe three patients with Fontan-associated liver disease who developed hepatocellular carcinoma (HCC). The first patient was a 28-year-old woman who had undergone the Fontan operation (FO) at the age of 4years. She was diagnosed with HCC (cT4aN0M0, Stage IVA, UICC 8th edition), for which she underwent extended posterior right sectionectomy and partial hepatectomy of S2. She developed recurrence of peritoneal dissemination after 12months, and she was alive 18months after surgery. The second patient was a 43-year-old man who had undergone the FO at the age of 3years. He was diagnosed with HCC (cT2N0M0, Stage II), for which he underwent laparoscopic-assisted partial hepatectomy of S3. He remained free from recurrent HCC for 17months. The third patient was a 21-year-old woman who had undergone the FO at the age of 3years. She was diagnosed with HCC (cT3N0M0, Stage III), for which she underwent laparoscopic-assisted partial hepatectomy of S2 and S4. She remained free from recurrent HCC for 30months. We reviewed 18 surgical cases of HCC arising from Fontan-associated liver disease, including our 3 cases, and found that a high preoperative alpha-fetoprotein concentration might be a predictor of HCC recurrence.

Laparoscopic modular extended right posterior sectionectomy for hepatocellular carcinoma guided by projection plane extension from the right hepatic vein

BackgroundExtended right posterior sectionectomy (ERPS) preserves more liver parenchyma than right hepatectomy when hepatocellular carcinoma (HCC) is in the right posterior section (RPS) and part of the right anterior section (RAS), but the difficulty lies in the precise determination of the cutting plane, especially under laparoscopy.[Torzilli et al. in Annals of surgery. 247:603–611, 2008] If the right hepatic vein (RHV) is not invaded by the tumor, it can help to divide the ventral and dorsal plane (VP, DP) as surgical landmark.[Makuuchi in International Journal of Surgery. 11:S47–S49, 2013] (Fig. 1) This study presented a laparoscopic modular ERPS (LMERPS) guided by projection plane extension from the RHV. MethodsA 56-year-old man was seen with HCC in the (RPS) and segment 8 following two laparotomies. After releasing intraperitoneal adhesions, the short hepatic veins were severed to expose the inferior vena cava (IVC). The right posterior Glission pedicle (RPGP) was clamped to control RPS inflow and allow determination of the demarcation line (DL) between the RPS and RAS using ICG fluorescence staining.[Chen et al. in Annals of surgical oncology. 29:2034–2040, 2022] Intraoperative ultrasound identified the RHV projection to satisfy the requirements of oncologic treatment. The VP and DP were incised along the DL and RHV projection. The RHV was exposed fully on the cutting plane and the tumor was completely removed finally. ResultsThe operation was completed in 265 min, with a blood loss of 50 ml. The diagnosis was HCC with a negative resection margin. The patient was discharged on postoperative day 8 without any complications. ConclusionLMERPS guided by a projection plane extending from the RHV is feasible and effective. Graphical Abstract [Display omitted]

Curative Resection for Metastatic Solid Pseudopapillary Neoplasm of Pancreas-a Case Series.

Solid pseudopapillary neoplasm (SPN) is an unusual tumor of the pancreas. Unlike ductal adenocarcinoma, SPN is commoner in young women and is indolent with better prognosis. Fifteen percent of patients, however, develop metastases, often synchronous and involving the liver or peritoneum. Owing to the paucity of cases, management of the metastatic disease is not clearly defined. Retrospective review of case notes of patients treated between 2006 and 2019. There were 53 patients with SPN of which 4 had hepatic metastases-3 synchronous and 1 metachronous. Two patients underwent simultaneous distal pancreatectomy and splenectomy with liver resection (right posterior sectionectomy and metastasectomy). One required right hepatectomy with metastasectomy for metachronous liver metastases. The other underwent a staged operation-remnant tumor excision with metastasectomy followed by right hepatectomy after portal vein embolization. All four patients are recurrence free on median follow-up of 38.5months. In view of the excellent prognosis, we recommend radical resection of both the primary lesion and metastases for SPN.

Laparoscopic versus open in right posterior sectionectomy: a systematic review and meta-analysis.

Laparoscopic liver resection (LLR) is now widely adopted for the treatment of liver tumors due to its minimally invasive advantages. However, multicenter, large-sample population-based laparoscopic right posterior sectionectomy (LRPS) has rarely been reported. We aimed to assess the advantages and drawbacks of right posterior sectionectomy compared with laparoscopic and open surgery by meta-analysis. Relevant literature was searched using the PubMed, Embase, Cochrane, Ovid Medline, and Web of Science databases up to September 12, 2021. Quality assessment was performed based on a modified version of the Newcastle-Ottawa Scale (NOS). The data were analyzed by Review Manager 5.3. The data were calculated by odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI) for fixed-effects and random-effects models. The meta-analysis included seven studies involving 739 patients. Compared with open right posterior sectionectomy (ORPS), the LRPS group had lower intraoperative blood loss (MD - 135.45; 95%CI - 170.61 to - 100.30; P < 0.00001) and shorter postoperative hospital stays (MD - 2.17; 95% CI - 3.03 to - 1.31; P < 0.00001). However, there were no statistically significant differences between LRPS and ORPS regarding operative time (MD 44.97; P = 0.11), pedicle clamping (OR 0.65; P = 0.44), clamping time (MD 2.72; P = 0.31), transfusion rate (OR 1.95; P = 0.25), tumor size (MD - 0.16; P = 0.13), resection margin (MD 0.08; P = 0.63), R0 resection (OR 1.49; P = 0.35), recurrence rate (OR 2.06; P = 0.20), 5-year overall survival (OR 1.44; P = 0.45), and 5-year disease-free survival (OR 1.07; P = 0.88). Furthermore, no significant difference was observed in terms of postoperative complications (P = 0.08), bile leakage (P = 0.60), ascites (P = 0.08), incisional infection (P = 0.09), postoperative bleeding (P = 0.56), and pleural effusion (P = 0.77). LRPS has an advantage in the length of hospital stay and blood loss. LRPS is a very useful technology and feasible choice in patients with the right posterior hepatic lobe tumor.

Purely laparoscopic living donor right posterior sectionectomy: expanding living donors in America

Background: Minimally-invasive hepatectomy in living donor transplantation remains an infrequent practice in American institutions, limited to few centers with expertise. The practice of living donation is further restricted by anatomical variants in certain donors where a standard right or left hepatectomy does not provide adequate donor remnant volume or sufficient graft weight for the recipient. Whenever feasible, the use of right posterior sector grafts can provide a suitable alternative. This video aims to showcase our approach to a purely laparoscopic right posterior sectionectomy for living donation.

Robotic right extended posterior sectionectomy using inferior-first approach

Background: Robotic hepatectomy has become increasingly common. Technological improvements and better understanding of the strengths and limitations of the platform have allowed for more complex minimally invasive resections of benign and malignant lesions. In this video, we demonstrate a safe approach to robotic right extended posterior sectionectomy using the inferior-first approach.