Laparoscopic anatomical liver segment seven resection with liver parenchymal transection following a priority approach.Introduction. The plane separating liver segment seven and eight is difficult to identify. One of the primary challenges is determining the anatomical plane of the liver for dissection.
In fact, there are two theories for this. First consideration is that the dorsal branch of the hepatic pedicle in liver segment eight frequently branches across the area where the right hepatic vein innervates segment seven of the liver. Another consideration is that the ischemia border between liver segment seven and eight may not completely cover the tumor area or provide sufficient tumor margins.
Thus, at present it is not possible to create a suitable boundary between segment seven and eight of the liver by dissecting only the hepatic pedicle in segment seven. Our center has implemented the liver parenchyma priority method after years of experience, prioritizing liver parenchyma dissection over liver pedicle disconnection while performing these surgeries, the entire hepatic blood supply was blocked as the liver parenchyma was intermittently detached, all without extending the surgical scope. The only modification made was to the order of the surgical processes, making it easier to block the incoming hepatic blood flow and decreasing the chance of bleeding from hilar dissection.
The liver parenchyma priority method is not influenced by anatomical variations, such as hepatic segment seven innervations by the dorsal branch of the hepatic pedicle crossing the right hepatic vein, which is advantageous for advancing and using anatomical liver resection surgery. We present the case of a 54-year-old male patient admitted to our hospital in September, 2022, whose liver mass had been present for one week. His medical history revealed hepatitis B.Abdominal contrast enhanced computed tomography revealed a mass with heterogeneous enhancement located at segment seven of the liver.
The measured value of alpha fetoprotein in this patient was 559.6 nanograms per milliliter. The Child-Pugh score indicated liver function grade A and the ICG clearance rate R15 was 6.2%The cancer was classified as stage A according to the BCLC algorithm, and stage I according to the CNLC algorithm. Further, 3D reconstruction revealed that the dorsal branch of the eight segment of the liver pedicle crosses the right hepatic vein and supplies the segment seven area of the liver.
If the traditional preferential dissection approach is used to reach the segment seven liver pedicle for revealing the ischemic line or a fluorescent staining is used, the resection range will not completely cover the entire segment seven area. Therefore, we adopted the liver parenchyma priority approach for the anatomical resection of the segment seven, thereby avoiding errors caused by this specific variation in the resection range. This surgery applies to all seven segment resections containing special portal vein variations.Protocol.
All methods described in this study were approved by the Ethics committee of Guangdong Provincial Hospital of Traditional Chinese medicine. Surgical indications and contraindications were based on the CSCO primary liver cancer diagnosis and treatment guidelines. Inclusion criteria.
Confirmed that the mass is located in the segment seven of the liver and identify it as a primary or secondary malignant tumor or benign liver diseases. Verify that the surgical procedure planned is the resection of the segment seven of the liver using the parenchyma priority method. Ensure that the preoperative Child-Pugh grade is A.Check that the future liver remnant represents more than 40%of the standard liver volume.
Exclusion criteria. Exclude cases where tumors invade the portal or hepatic veins. Exclude cases with intrahepatic or distant metastases of the tumor.
Exclude patients with vital organ pathology that prevents anesthesia administration and surgical intervention tolerance. Preoperative preparation. Ensure the availability of laparoscopic imaging systems, pneumoperitoneum images, and ultrasound scalpels.
Ensure the patient undergoes preoperative bowel preparation and preoperative risk assessment before anesthesia administration. For patients who take aspirin, aspirin should be discontinued before the surgery. Intravenously administer antibiotics 30 minutes before the surgery.
Dilute cefuroxime sodium 1.5 gram in 100 milliliters of 0.9%sodium chloride solution. Perform tracheal intubation under general anesthesia. Place an arterial catheter and a central venous catheter.
Ensure the central venous pressure at two to three millimeters of mercury. Surgical position. Place the patient in a supine split-leg position.
Raise the right waist by 15 degrees and ensure that the chief surgeon stands between the patient's legs.Surgery. Preparation phase. Ensure the surgeon washes their hands before the procedure.
Disinfect the skin at the surgical site extending 15 centimeters twice with 5%tincture of iodine and three times with 75%alcohol. Place sterile towels at the nipple line, the left midclavicular line, the right mid axillary line, and the bilateral anterior superior iliac spines exposing the surgical area. Trocar placement.
Make a two centimeters incision to the right of the umbilicus as a laparoscopic hole. Insert a pneumoperitoneum needle following the Veress method to establish pneumoperitoneum. Maintain pneumoperitoneum pressure at 12 to 14 millimeters of mercury.
Place a 12-millimeters trocar at four centimeters below the midline of the right clavicle from the rib margin. Place a five-millimeters trocar in the right anterior axillary line four centimeters below the rib margin. Subsequently place five millimeters and 10 millimeters trocars in the front of the midline of the sternum and two centimeters from the lower edge of the xiphoid process respectively.
Adjust the angle of the operating table, so that the patient's head is positioned higher than their feet, high on the right and low on the left. Dissect the right liver and suspend the right hepatic vein. In size and dissect the peritoneum in front of the inferior vena cava and the third hepatic portal using an ultrasound knife after routine exploration of the abdominal cavity.
Trace the inferior vena cava from the foot side toward the head side. Expose the thick right posterior inferior hepatic vein and short hepatic veins. Use sutures to ligate the right posterior inferior hepatic vein and then cut it using an ultrasonic knife.
Use vascular clips to ligate the short hepatic veins freeing the posterior hepatic tunnels. This allows for adequate exposure of the anterior interstitial space of the inferior vena cava and the interstitial space adjacent to the inferior vena cava. Detach the right triangular ligament and coronary ligament of the liver using an ultrasound knife with an assistant performing adequate exposure, thus completely freeing the right liver.
Separate the Makuuchi ligament using an ultrasound NIF. Pull the right liver toward the left abdomen with the help of an assistant to expose the root of the right hepatic vein and the inferior vena cava. Separate the right hepatic vein bluntly along the hepatic vein recess and the anterior space of the inferior vena cava and suspend the root of the right hepatic vein with a vascular identification strap as the marker for subsequent liver parenchyma dissection.
Liver section. Dissect the hepatic parenchyma along the bare area of the liver using an ultrasonic knife and locate the main trunk of the right hepatic vein. Use a combination of blunt and sharp separation using an ultrasound knife for dissecting the right hepatic vein.
Locate the segment eight severed dorsal branch of the hepatic pedicle in front of the main trunk of the right hepatic vein ligate and disconnect it. Find the segment seven liver pedicle behind the main right hepatic vein and use Hem-o-lo to clamp it and disconnect it using an ultrasonic knife or scissors. Cut off the liver parenchyma along the right hepatic vein from the foot side to the head side with the root of the right hepatic vein as the marker on the head side and the inferior vena cava as the marker on the backside to determine the level of liver dissection.
Expose the main trunk of the right hepatic vein within the liver segment along the right hepatic vein throughout the entire process. The anesthesia team must reduce central venous pressure and minimize surface CIV hole bleeding caused by venous filling. Use bipolar electrocoagulation for small CIV hole bleeding.
Large CIV holes often require suturing to stop bleeding. Pay attention to protecting the dorsal branch of segment eight that flows back from the right hepatic vein in front of the right hepatic vein while segmenting the liver parenchyma between segment seven and segment eight. Dissect the liver on the right side of the hepatic vein flowing back from the dorsal branch of segment eight.
Further cut off the hepatic vein branches that flow back to the right hepatic vein, one by one. Fully expose the right hepatic vein from main trunk to the root and cut off the liver parenchyma on the right side of the right hepatic vein with the main trunk of the vein and the inferior vena cava as the plane to completely remove segment seven of the liver. Take out the specimen.
Put the surgical specimen into the specimen bag. Depending on the situation, extend the incision of sleeve A and remove the specimen. Place an abdominal drain at the hepatectomy site and one at the foramen of Winslow.
Suture all the trocar incisions layer by layer. Postoperative care. Make the patient lie in the anesthesia recovery room after surgery for approximately one H until the patient is fully awakened.
Monitor oxygen supply to ensure patient oxygenation during this period. Return the patient to the ward from the operating room once the patient is fully awake. Follow up.
Instruct the patient to return to the hospital after one month with subsequent follow-ups every three to six months for blood tests and enhanced CT examinations. Representative results. In this representative case, the liver parenchyma priority approach for anatomical resection of liver segment seven was successfully followed in a 54-year-old male patient.
The total operative time was 110 minutes with an estimated intraoperative blood loss of 100 milliliters. The patient recovered successfully on the seventh postoperative day and was discharged from the hospital without any postoperative complications, such as bleeding, bowel leakage, subphrenic infection, dropsy of the right chest, or hepatic failure. Pathological results showed HCC and postoperative CT suggested complete resection of the tumor.
From January, 2019 to April 2023, 27 patients were successfully treated with liver parenchyma priority laparoscopic anatomical liver segment seven resections, and none of the surgeries were converted to open surgery. The average age of the patients was 56.8 plus or minus 13.0 years. The average tumor diameter was 3.24 plus or minus 1.47 centimeters.
And the average surgical duration was 74.5 plus or minus 49.7 minutes. The average blood loss encountered during the surgery was 260.9 plus or minus 391.8 milliliters. No patient required blood transfusions during the operation.
The drainage tube removal time was 7.7 plus or minus 1.9 days, and the postoperative hospitalization time was 8.6 plus or minus 2.1 days. Postoperative pathological analysis confirmed one case of hepatocellular adenoma, one case of cholangiocarcinoma, and 25 cases of HCC. All patients were successfully discharged and two patients developed right pleural effusion after surgery which was cured by thoracic puncture drainage.
No patient experienced serious complications, such as biliary fistula, subphrenic infection, or liver failure. After surgery, 22 patients received transarterial chemoembolization, TACE, adjuvant treatment and underwent laboratory and imaging examinations in routine outpatient clinics. Postoperative reexamination of liver function revealed that indicators such as alanine transaminase, ALT, alkaline phosphatase, serum bilirubin, and plasma albumin quickly recovered and returned to normal by the fifth day after surgery.
There were no deaths during the operation. The follow-up period ranged from one to 44 months with a median of 13 months. Two patients experienced postoperative tumor recurrence.
The detailed data for all patients are shown in table three. This procedure was used for the surgical treatment of all 27 patients included in the study. Compared with traditional laparoscopic seven anatomical liver segment resection with a priority hepatic pedicle approach, this procedure significantly reduces surgical time without increasing intraoperative bleeding, postoperative duration of hospitalization, or incidents of complications.
