Spiegel Lobe Research Articles

PE074 Robotic Spiegel lobe liver resection with thrombectomy for level II-IV inferior vena cava thrombus: A safe technique for better control of the retrohepatic IVC

PE074 Robotic Spiegel lobe liver resection with thrombectomy for level II-IV inferior vena cava thrombus: A safe technique for better control of the retrohepatic IVC

Robotic Right Hepatectomy with En Bloc Caudatectomy for Bismuth IIIa Hilar Cholangiocarcinoma: A Video Demonstration of Left-Liver-First Anterior Radical Modular Orthotopic Right Hemihepatectomy.

Minimally invasive resection for perihilar cholangiocarcinoma is a complicated and technically demanding surgical procedure. Radical surgical resection is regarded as the best treatment for hepatic hilar cholangiocarcinoma.1,2 Right hepatectomy with caudate lobe resection is necessary as the treatment for bismuth IIIa hilar cholangiocarcinoma.3 The left-liver-first anterior radical modular orthotopic right hemihepatectomy (LARMORH), which can simplify surgical steps and decrease procedural difficulty, may be a better choice for Bismuth IIIa hilar cholangiocarcinoma.4 However, there are no reports of this approach using robotic technique for this operation. We will provide a detailed introduction to this method through this video. A 45-year-old female patient was diagnosed with a hilar cholangiocarcinoma. Following a 7-day percutaneous biliary drainage of the left intrahepatic bile duct and obtaining informed consent, we performed a robotic radical resection of the HCCA using the LARMORH approach. The patient was positioned supine with the entire bed elevated 20° and tilted 15° to the left. Trocars were placed in position (Fig. 1). After entering the abdominal cavity, it was explored for tumor metastasis. The surgery adopted a left approach, initially exploring the left hepatic artery and vein to further assess resectability. After confirming resectability, the right hepatic artery and gastroduodenal artery (GDA) were dissected. The common bile duct was dissected and transected at its distal end, ensuring R0 surgical margins. Lymph nodes were cleared from the foot side to the head side, confirming the metastasis to the lymph node group 13a, so we further cleared the group 16 and 9 lymph nodes.5 Subsequently, we approached the resection of the right half and the entire caudate lobe with the reverse thinking of left hepatic resection mode, preserving only the left branch of the portal vein and left hepatic artery, and dissecting the liver tissue along the resection plane of the left liver. After transection of the left hepatic duct, the activity space of the left liver was larger and the caudate lobe could be better exposed. The Spiegel lobe was lifted to the right in a "turn the page" fashion for in situ resection of the entire caudate lobe and the right half of the liver. Finally, a bilioenteric anastomosis was performed using the Roux-en-Y method. Robotic right hepatectomy with caudate lobectomy was successfully performed in 450 min, with an estimated blood loss of 200ml. The histological grading was determined as T1aN1M0 (stage IIIB) on the basis of postoperative pathological biopsy results. The patient achieved a satisfactory postoperative recovery and was discharged on the 14th postoperative day without any major complications. Following the operation, the patient received capecitabine chemotherapy according to the Chinese Society of Clinical Oncology (CSCO) criteria. Since September 2022, our team has completed three radical resections for Bismuth IIIa HCCA using this technique. All patients achieved a satisfactory postoperative recovery without any further complications. Robotic left-liver-first anterior radical modular orthotopic right hemihepatectomy for Bismuth IIIa HCCA is both safe and feasible. This method may provide a new surgical approach for patients with type IIIA HCCA or liver diseases requiring right hemihepatectomy combined with total caudate lobectomy.

Radiological Vascular Anatomy of the Caudate Lobe of the Liver Required for Transarterial Chemoembolization of Hepatocellular Carcinoma.

The caudate lobe is located between the bilateral hepatic lobes and is divided into three subsegments: the Spiegel lobe, paracaval portion, and caudate process. The caudate artery arises from various sites of the bilateral hepatic arteries as an independent branch, common trunk, or arcade. Extrahepatic arteries can enter the caudate lobe mainly by the right inferior phrenic artery. The caudate artery also supplies the main bile duct and posterior aspect of segment IV. Although catheterization into the caudate artery is occasionally difficult because of its small size and sharp angulation, selective embolization of a tumor feeder is a significant prognostic factor in patients with hepatocellular carcinoma originating there. Therefore, we should recognize the peculiarity of its vascular anatomy and should be familiar with catheterization and embolization techniques.

Is laparoscopic surgery a preferred option for benign conditions in the caudate lobe of the liver?

Laparoscopic hepatectomy has become a common management strategy for liver tumors owing to its less invasive nature and enhanced visual perspective. Yet, its use in the caudate lobe poses challenges. This study evaluates the experiences of patients who underwent laparoscopic hepatectomy for hepatic tumors in the caudate lobe and aims to propose strategies for performing such procedures. We retrospectively analyzed the clinical data of twelve patients who underwent laparoscopic hepatic caudate lobe resection at the Department of Hepatopancreatobiliary Surgery, Second Affiliated Hospital of Kunming Medical University. All twelve laparoscopic procedures were successful, with none requiring conversion to open surgery. The surgical methods varied: five cases involved simple resection of the Spiegel lobe, one case involved total caudate lobe resection, three cases involved paravena cava lobe resection, and three cases involved resection of the caudate process. The operation time ranged from 49 to 319min (mean, 219min). Intraoperative blood loss ranged from 20 to 500ml, averaging 194ml. No patients needed blood transfusions during or after the operation, and there were no instances of postoperative bleeding, bile leakage, or abdominal infection. Given adequate control of hepatic inflow, sufficient exposure to the surgical field, and an appropriate approach, laparoscopic hepatectomy in the caudate lobe could potentially become a standard surgical technique.

Laparoscopic Right Colectomy with D3 Lymphadenectomy and Spiegel Lobe Resection Indocyanine-green Guided

Laparoscopic Right Colectomy with D3 Lymphadenectomy and Spiegel Lobe Resection Indocyanine-green Guided

Standardized and Feasible Laparoscopic Approach for Tumors Located in the Caudate Lobe

Although laparoscopic hepatectomy has been widely used in the management of liver tumors for its reduced invasiveness and magnified view, in the caudate lobe it remains challenging especially for patients with cirrhosis. Thus, this study aimed to evaluate patients undergoing laparoscopic hepatectomy for hepatic tumors in the caudate lobe and establish strategies for performing such procedure. Laparoscopic hepatectomy in the caudate lobe was performed in nine patients. We performed inflow control to reduce bleeding during hepatic transection and retraction of the left lateral section to the cranial side to obtain a sufficient surgical field using a Nathanson liver retractor. We approached tumors in the Spiegel lobe (SP) from caudal side for segment 1 (S1) partial hepatectomy and from caudal and left side for Spiegel lobectomy, the lower paracaval portion (PC) from caudal side for S1 partial hepatectomy, and the upper PC from caudal and bilateral side for total caudate lobectomy. In 6 cases the tumors were in the SP and in 3 cases in the PC. The types of laparoscopic hepatectomy performed were total caudate lobectomy (n=1), Spiegel lobectomy (n=2), and partial hepatectomy of segment 1 (n=6). All the tumors were curatively resected, and no patient had complications. Operative time for tumors located in the PC was significantly longer than that for tumors located in the SP. Laparoscopic hepatectomy in the caudate lobe was safely performed for five patients with liver cirrhosis. Laparoscopic hepatectomy in the caudate lobe may become the standard surgical technique with hepatic inflow control, sufficient surgical field exposure, and appropriate approach.

Crucial Roles of the Assistant Surgeon During Laparoscopic Left Hemihepatectomy.

BackgroundAlthough left hemihepatectomy has been widely performed via the laparoscopic approach, the roles of the assistant surgeon have not been well-documented so far. We herein present our standardized procedures of laparoscopic left hemihepatectomy without Spiegel’s lobe resection, focusing on the crucial roles of the assistant surgeon.MethodsDuring laparoscopic left hemihepatectomy without Spiegel’s lobe resection, countertraction by the assistant surgeon is quite important especially during isolating the left Glissonean pedicle and transecting liver parenchyma. When securing the left hepatic pedicle using the Glissonean approach, the assistant surgeon pushes Segment 4 of the liver cranially and pulls the tape encircling the hepatoduodenal ligament caudally in the opposite way, orthogonal to the direction of the laparoscopic forceps toward the left portal triad. During liver parenchymal transection, the assistant surgeon pulls the hanging tape across the left lobe of the liver in order to provide a wide and stable liver transection plane.With this standardized technique, nine cases of laparoscopic left hemihepatectomy were performed over the last two years in our department, and the perioperative data were retrospectively analyzed.ResultsThe median age of the nine patients was 70 years (range: 58 - 84 years). Most of the patients were males (77.8%). Five of nine patients were diagnosed with colorectal liver metastasis, two with hepatocellular carcinoma (HCC), one with inflammatory pseudotumor, and the other one with hepaticolithiasis. There were no conversions to open surgery. The median operative time and estimated blood loss were 337 minutes (range: 219 - 478 minutes) and 100 ml (range: 41 - 375 ml), respectively. The median length of postoperative hospital stay was nine days (range: 7 - 16 days). Major complications (Clavien-Dindo classification grade III or more) were not encountered in our cohort postoperatively.ConclusionWe presented here our standardized assistant roles during laparoscopic left hemihepatectomy without Spiegel’s lobe resection, which was revealed to be safe and feasible in our cohort.

Laparoscopic Left Hepatectomy with Resection of the Spiegel Lobe Using the Modified Caudate Lobe-First Approach.

Laparoscopic left hepatectomy with resection of the Spiegel lobe remains a technically demanding procedure as it is a deep-seated area surrounding the inferior vena cava (IVC). Mobilization of the Spiegel lobe requires safe exposure of the ventral side of the IVC while dissecting the short hepatic veins from the IVC. Additionally, wide space is needed to isolate the left Glissonean pedicle (Glt). We used a modified caudate lobe-first approach to overcome this challenge Maeda (J Hepato-Bil Pancreat Sci 25:335-41, 2018), Li (J Gastrointest Surg 23:1084-5, 2019), Homma (Surg Endosc 33:3851-7, 2019). The ischemic area was confirmed after isolating the left and middle hepatic artery and left portal vein. After mobilizing the left lateral section, the Spiegel lobe was divided from the notch, which is the boundary between the caudate lobe and the Spiegel lobe, toward the middle hepatic vein (MHV). The Spiegel lobe was safely detached from the IVC with a short hepatic vein transected with the caudo-dorsal view. The Glt could be easily isolated due to the wide space on the ventral side of the IVC. After dividing the left hepatic duct, the MHV was exposed continuously from the root to the periphery, and parenchymal transection was completed by connecting the demarcation line and MHV. The total operation time was 430 min, and estimated blood loss was minimal. The patient was discharged on postoperative day 6 without complications. The modified caudate lobe-first approach can be used to safely perform laparoscopic left hepatectomy combined with the Spiegel lobe resection.

Demonstration of the right-side boundary of the caudate lobe in a liver cast.

There have been historical arguments about the boundary of the caudate lobe of the liver. Kumon M first advocated the definition of the caudate lobe based on the portal segmentation of the liver in 1985, and classified it into three parts, Spiegel lobe, paracaval portion and caudate process. Prof. Couinaud defined the dorsal liver as a union of segments I and IX in 1994, based on the spatial position to the major hepatic veins, hilar plate and inferior vena cava. In Couinaud's classification, right-side of the dorsal liver is supplied by the branches from the posterior and anterior sections. In the present study using a liver cast, we found a paracaval branch of the portal vein branching from the right portal vein on the dissecting plain along the Rex-Cantlie's line. We also found several branches from the posterior portal vein to the right-side of the paracaval portion, but they should be defined to belong to the posterior sections.

Left Intercostal Approach for Laparoscopic Isolated Total Caudate Lobectomy (with Video)

BackgroundLaparoscopic total caudate lobectomy remains a challenging procedure because of its deep location (Xu et al., Surg Endosc. 35:1138–47, 2021). Placement of intercostal ports can overcome the barriers of the ribcage for laparoscopic access (Hayashi et al., PLoS One.15:e0234919, 2020). We herein present a novel technique in which a left intercostal port was used as the main working port during laparoscopic caudate lobectomy. MethodsAn 84-year-old man with a 1-cm intrahepatic cholangiocarcinoma located in segment 1 (S1) was referred to our hospital. We planned laparoscopic isolated caudate lobectomy using a left intercostal port as the main working port. The patient was placed in the supine position. A 12-mm left intercostal port with a balloon was introduced in the seventh intercostal space as the main working port. After Arantius’ ligament was divided, the left Glissonean pedicle of S1 (G1) was divided using an endo-stapling device. The surgeon moved to the right side of the patient and divided the right G1, followed by transection to the inferior right hepatic vein. Again, the surgeon moved to the left side, and the left intercostal port was used for mobilization of the Spiegel lobe and parenchymal resection using a cavitron ultrasonic surgical aspirator, exposing the root of the left and middle main hepatic veins for completion of total caudate lobectomy. ResultsThe operative time was 264 min and blood loss was 400 mL. The patient was discharged on a postoperative day 9 without complications. ConclusionsA laparoscopic approach to the caudate lobe using a left intercostal port is a new and ideal technique providing effective manipulation.

The postoperative choledochoscopy in the management of the residual hepatolithiasis involving the caudate lobe: A retrospective study.

To reveal the role of the postoperative choledochoscopy in treating the residual calculi in the caudate lobe (CL) of the liver.We recruited 66 patients with T-tube/percutaneous transhepatic cholangioscopy tract who still had residual gallstones in the CL at least 6 weeks after the operation. Imaging examinations determined the gallstones’ locations in the patients, and all of them underwent the postoperative choledochoscopic examination through the T-tube/percutaneous transhepatic cholangioscopy tract for therapeutic intervention.Among the 66 patients, the residual gallstones were mostly located in the Spiegel lobe (48/66, 72.7%), and the residual gallstones that located in the origin of the CL bile branches were successfully determined in the 57 patients (57/66, 86.4%), the remaining 9 patients were unclear because the proximal ducts were severely narrow or even atresia. The mean frequency of the postoperative choledochoscopy was 3.6 (range, 1–10) times. There were 9 patients with complications, and no mortality occurred. In the origin-proved 57 patients, 6 patients failed to remove the gallstones altogether, and the final residual gallstone clearance rate was 77.3% (51/66). There was no significant difference between the Spiegel lobe and the other parts of the CL in determining the bile duct's origins, gallstone clearance rate, and complications. However, the frequency of choledochoscopy in the other parts of the CL was more than in the Spiegel lobe.The postoperative choledochoscopy, an essential method for treating the residual gallstones in the CL, commands high efficiency for calculi extraction and fewer complications. The main reasons for failing to remove the residual gallstones are that the bile duct's origins could not be determined, and the distal bile ducts are atretic in the CL.

Hepatic Infarction after Transjugular Intrahepatic Shunt Creation

A 23-year-old woman with recent onset of ascites was diagnosed with Budd-Chiari syndrome using ultrasonography, with a patent inferior vena cava but occlusion of all major hepatic veins. She underwent transjugular intrahepatic shunt creation and afterwards developed hypotension and abdominal distension. Computed tomography (CT) showed intraperitoneal hemorrhage and infarction of the caudate lobe (Fig 1–3). The left hepatic artery supplying the Spiegel lobe was attenuated, and no arterial supply to the caudate process was visualized.

Newly-revised Pringle maneuver using laparoscopic Satinsky vascular clamp for repeat laparoscopic hepatectomy.

It has been known that repeat laparoscopic hepatectomy (RLH) after open hepatectomy is technically challenging because of adhesions around the hilum. It is quite often that conventional tourniquet technique for the Pringle maneuver is difficult in RLH, and we introduced Laparoscopic Satinsky Vascular Clamp (LSVC) for inflow control in RLH. The Spiegel lobe is the anatomical landmark in LSVC technique. If a space behind the hepatoduodenal ligament and the Spiegel lobe was obtained, LSVC was applied laterally from the left side of the hepatoduodenal ligament, whereas LSVC was vertically applied for those with obstruction of a space behind the hepatoduodenal ligament. We performed 14 cases of RLH for those with histories of open hepatectomies by lateral (n = 6) and vertical (n = 8) LSVC technique with successful inflow control, confirmed by intraoperative Doppler ultrasound. Five patients underwent 2 or more previous histories of hepatectomies. The RLH included segmentectomy (n = 1), subsegmentectomy (n = 2) and partial hepatectomy (n = 11). The median time for the Pringle maneuver, operative time, and blood loss was 47min, 237.5min, and 160mL. All the patients completed pure laparoscopic hepatectomy. In conclusion, LSVC technique is a safe and reliable technique for the Pringle maneuver in RLH.

Reply to: "Predicted Volume or Actual Weight for Graft Selection Policy in Living-donor Liver Transplantation".

We are grateful to Dr Ikegami and his colleagues for their interest and useful comments regarding our recently published article.1 We claimed that small grafts with 0.6% ≤ actual graft-to-recipient weight ratio (GRWR) < 0.8% should be used as safely as large grafts with 0.8% ≤ actual GRWR regardless of lobe selection, and that 0.6% in GRWR was reasonable as the minimum requirement of graft volume (GV) in living-donor liver transplantation. However, small grafts should be indicated carefully for high-risk cases. We extracted data on estimated and actual GRWR from the electronic medical record system and demonstrated their relationship in the article (Figure S1A). However, the dataset may not be sufficient to fully answer their questions. This is because missing data on estimated GRWR were not negligible, and the time of measurement of the recipients’ preoperative weight was inconsistent. Therefore, we recollected preoperative volumetric imaging data for as many cases as possible and rechecked the estimated GV for each case. Estimated and actual GRWRs were calculated by dividing graft weight by recipient weight just before living-donor liver transplantation. We retrieved the data of 384 donor grafts of 417 cases in the original cohort. The following formula was used for the volume-to-weight conversion of grafts: estimated graft weight (g) = 0.91 × estimated GV (mL). The coefficient has been used at our institution based on our experience from previous cases. As demonstrated in Figure 1, the actual GRWR was strongly correlated with the estimated GRWR (actual GRWR = 0.95 × estimated GRWR + 0.07, P < 0.001). However, 10 cases with an actual GRWR <0.6% were identified, whose GRWR was overestimated preoperatively as ≥0.6%.FIGURE 1.: Correlation between the estimated GRWR and the actual GRWR. The solid line represents the best-fit line. Gray upper and lower shaded areas indicate 95% confidence intervals for the estimates. ρ, Spearman rank correlation coefficient; GRWR, graft-to-recipient weight ratio.We next compared the safety of small grafts with 0.6% ≤ estimated GRWR < 0.8% against that of large grafts with 0.8% ≤ estimated GRWR. Multivariate analysis demonstrated that small grafts were not a significant risk factor for overall graft survival (P = 0.90; hazard ratio: 0.90; 95% confidence interval: 0.62-1.70). However, Kaplan-Meier curve of small grafts was slightly inferior to that of large grafts (Figure 2). This may partly be due to the aforementioned overestimation of small graft size. The comparison between the extra-small grafts with estimated GRWR <0.6% and small grafts was not realistic because only 7 extra small grafts were included.FIGURE 2.: Unadjusted Kaplan-Meier graft survival curves between extra small grafts with estimated GRWR <0.6%, small grafts with 0.6% ≤ estimated GRWR < 0.8%, and large grafts with 0.8% ≤ estimated GRWR. GRWR, graft-to-recipient weight ratio; LDLT, living-donor liver transplantation.To solve the issue of graft size discrepancy, especially the overestimation of small grafts, we recently changed the software for preoperative analysis of GV. The parenchymal cutting plane has been strictly determined for each case before the procedure by paying attention to the middle hepatic vein/inferior vena cava, Spiegel lobe, and peripheral segmental branches of the portal vein in 3D imaging. At this point, we have not yet encountered any small graft cases with an actual GRWR <0.6%. Regardless of this fact, we are aware that graft selection should be cautiously determined if the estimated GRWR is close to 0.6%, and our correction coefficient of 0.91 should be reevaluated from a considerable number of cases because of volume analysis modification. Furthermore, as they stated, adjusting factors such as donor age (responsible for causing estimation errors in liver volumetry) is essential to accurately predict GV.2 Once again, we greatly appreciate the helpful insights provided by Dr Ikegami and his colleagues.

Isolated caudate lobectomy using a modified hanging maneuver.

The caudate lobe is located deep in the dorsal portion of the liver. Complete resection is an extremely demanding surgery due to the limited surgical field, especially in cases with severe intra-abdominal complications. A major concern of isolated caudate lobectomy is the difficulty associated with securing the contralateral visual field during parenchymal transection. To overcome this issue, we present a new technique for isolated caudate lobectomy that uses a modified hanging maneuver. We performed an anatomical isolated caudate lobectomy via the high dorsal resection technique using our new modified hanging maneuver in two patients with HCC in November and December 2019. Patient 1 was severely obese, so the upper abdominal cavity was occupied by a large amount of great omental fat, and fibrous adhesions were observed around the spleen. Patient 2 had undergone six preoperative treatments, and a high degree of adhesion was observed in the abdominal cavity around the liver. It was difficult to secure the surgical field due to severe abdominal complications in both cases. The total operation times in these two cases were 617 and 763min, respectively, while the liver parenchymal dissection times of the caudate lobe were 96 and 108min, respectively. The resection margin was negative in both patients (R0). Neither patient had any complications after surgery; both were discharged on postoperative day 14. Our modified hanging maneuver is useful, particularly in cases with a narrow surgical field due to severe adhesions, bulky tumors, and/or hypertrophy of the Spiegel lobe.

Resection of a Large Hepatocellular Carcinoma Located in the Dorsocaval Spiegel Lobe at the Origin of the Inferior Vena Cava Ligament —A Case Report—

Resection of a Large Hepatocellular Carcinoma Located in the Dorsocaval Spiegel Lobe at the Origin of the Inferior Vena Cava Ligament —A Case Report—

Definition of the caudate lobe of the liver based on portal segmentation.

Models of liver corrosion were developed by injecting colored Mercox, epoxy resin, silicon rubber and other materials into the portal vein, hepatic artery, bile duct and hepatic vein of autopsied livers. The glissonean or venous branches that obstructed the view of the caudate lobe of the liver were subsequently removed. The detailed anatomy of the caudate vessels was studied and the three parts of the caudate lobe (Spiegel lobe, paracaval portion and caudate process) were defined based on portal segmentation. Caudate portal branches should be defined as dorsal branches arising from the main trunk, or from the first order branches of the portal vein covering the hepatic region in front of the inferior vena cava. The hepatic region, where the internal branches from segment eight cover the front of the inferior vena cava, should be defined as segment eight, and not as the paracaval portion. Prof. Couinaud defined the right side of the caudate lobe as segment IX based on the spatial position; however, this classification of the caudate section seemed to lack consistency with that of other hepatic segments, which were defined based on portal segmentation. We have sustained the dogma that any hepatic segment should be defined based on portal segmentation, and our classification of the definition and boundary of the caudate lobe, which was published in 1985, has sufficient consistency to be used as an international standard.

Colorectal cancer liver metastases within the central and peripheral segments: Parenchymal sparing surgery adaptation

BackgroundThe debate over the surgical strategy optimization in colorectal cancer patients with liver metastases (mCRC) has been ongoing in the last 20 years. However, parenchyma sparing surgery (PPS) in cases of hard to reach liver cites (HTRLC) remain to be controversial. MethodsA prospective analysis of 185 mCRC patients performed who were devided in two groups depending by predominant liver cite localization. Peripherally localized metastases (PLM) (n = 107) (S2, S3, S6, S7, Spiegel lobe and subcapsular area 1–2 cm below the liver surface). Group 2 included those with metastases localized in HTRLC (n = 78) - metastatic lesions of the “right venous core”, portal and caval hilum, paracaval part of S1, “deep” parenchyma cites of S5, S8 and S4. ResultsIn 26 (33,3%) and 32 (29,9%) patients of HTRLC and PLM, respectively, performed one liver re-resection (0,62). In HTRLC group 2 and more re-resection were performed in 7 (8,9%) cases while in PLM in 11 (10,3%), p = 0,76. Postoperative major morbidity was 24,4%, 21,8% (p = 0,15) and mortality 8,9%, 4,6% for HTRLC and PLM groups, respectively. R1v principles were implemented in 24 (30,7%) cases with centrally located metastases and in only 6 cases (5.6%) with peripheral localized metastases (p = 0,001). Cumulative 3-year disease-free survival (DSF) for PLM and HTRLC groups was 63% and 41% (p = 0,008). DFS for R1v (n = 24) and R0 (54) cochorts in HTRLC group was 33% and 43%, respeсtively (p = 0,44). ConclusionsPrinciples of the PPS tactic provides an adequate removal of metastatic lesions in hard to reach liver cites allowing to maintain organ functions and increases the feasibility of the repeated liver resections in case of the initial disease progression.

Robotic anatomic isolated complete caudate lobectomy: Left-side approach and techniques

BackgroundTo demonstrate the surgical procedures and techniques of the robotic anatomical isolated complete caudate lobectomy. MethodsA retrospective analysis was performed on the demographic, operative, postoperative outcomes of seven patients who underwent robotic anatomical isolated complete caudate lobectomy at our department from January 2018 to November 2019. Mobilization of the left lateral and Spiegel lobe, dissection of the short hepatic veins and liver parenchyma transection from the dorsal plane of middle and right hepatic vein were crucial procedures for the robotic left-side approach. Anatomic complete caudate lobectomy was defined as total removal of the caudate lobe, in which the dorsal middle and right hepatic vein, the inferior vena cava and its right side were fully exposed on the raw surface. ResultsAll patients successfully underwent the robotic anatomical isolated caudate lobectomy with a left-side approach without conversion to laparotomy, and without Clavien-Dindo Grade III or higher complications. The average tumor diameter was 65.00 ± 10.61 mm, the average operation time was 212.00 ± 74.53 min, the median bleeding loss was 100 mL, and the average postoperative hospital stay was 8.71 ± 4.89 d, respectively. There were four patients with primary hepatocellular carcinoma, one with tumor recurrence five months after surgery and three patients were free of recurrence. All patients survived at the last follow-up. ConclusionRobotic anatomical isolated complete caudate lobectomy with a left-sided approach is safe and feasible for selected patients.

Influence of the Glissonean Pedicle Transection Approach in Spiegel Lobe-Preserving Left Hepatectomy on Spiegel Lobe Volume and Remnant Liver Functions.

The extrahepatic surgical technique in liver resection can be divided into glissonean pedicle transection and glissonean separated transection approaches. In this study, we compared remnant liver function and liver regeneration involving the Spiegel lobe between these two approaches regarding Spiegel lobe-preserving left hepatectomy. We enrolled 31 patients who underwent Spiegel lobe-preserving left hepatectomy for malignant hepatobiliary diseases between April 2008 and January 2020. The postoperative Spiegel lobe volume was measured using a volume analyzer at 3 and 6months postoperatively. Of the 31 patients, 22 and 9 were included in the glissonean separated transection and glissonean pedicle transection groups, respectively. There was no significant between-group difference in the preoperative Spiegel lobe volume. However, the volumes at 3 and 6months postoperatively were significantly larger in the glissonean pedicle transection group than in the glissonean transection group (29.92mL vs. 13.00mL; P < 0.001 and 28.43mL vs. 15.01mL; P < 0.001, respectively). There was no significant between-group difference in postoperative remnant liver function. The postoperative Spiegel lobe volume was larger, and liver regeneration was better with the glissonean pedicle transection approach because of transection for Spiegel branch of the portal vein. It is desirable to preserve Spiegel branch in possible cases when surgeons select the glissonean separated transection approach based on the location and size of the tumors.