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Case Report
This protocol describes a laparoscopic anatomical right anterior sectionectomy utilizing the Laennec capsule concept, combined with comprehensive preoperative therapy. The approach enables precise tumor resection in hepatocellular carcinoma (HCC) cases closely associated with major vascular structures, improving surgical safety, efficacy, and long-term patient outcomes.
This paper presents a laparoscopic anatomical resection technique for hepatocellular carcinoma (HCC) utilizing the Laennec capsule concept. The goal of this protocol is to improve surgical precision and safety during complex liver resections, particularly in tumors closely associated with vital vascular structures, by ensuring clear identification and dissection of critical anatomical landmarks. Surgical resection remains the primary curative treatment for hepatocellular carcinoma (HCC), but laparoscopic anatomical right anterior sectionectomy becomes particularly challenging when tumors are closely associated with major vascular structures, as this increases the risk of significant bleeding. Comprehensive preoperative treatment, including targeted therapy, immunotherapy, and hepatic arterial infusion chemotherapy (HAIC), can reduce tumor size and improve surgical outcomes, making previously borderline resectable tumors operable. In this case, a 75-year-old patient with a tumor in segment 8 (S8) of the liver, closely associated with major vascular structures, underwent two cycles of preoperative treatment. This reduced the tumor size from 6 cm by 5 cm to 4.5 cm by 3.1 cm. Laparoscopic anatomical right anterior sectionectomy was performed using the Laennec capsule, an anatomical structure that aids in vascular dissection. The procedure lasted 240 minutes with minimal blood loss (200 mL). The tumor was successfully resected with negative surgical margins, and the patient was discharged on the seventh postoperative day without complications. Postoperatively, the patient was monitored for signs of liver dysfunction and underwent routine imaging to assess for recurrence. Follow-up included liver function tests and regular CT scans, showing no recurrence after 6 months. This case demonstrates that the combination of the Laennec capsule technique and comprehensive preoperative treatment allows for precise, minimally invasive resections of HCC tumors closely associated with vascular structures, providing a safe and effective solution to challenging liver tumors with minimal intraoperative complications and promising postoperative outcomes.
Hepatocellular carcinoma (HCC) is a significant global health concern, representing 75% to 85% of primary liver cancers. It ranks as the 6th most common malignancy worldwide and is the 4th leading cause of cancer-related deaths globally1. In China, HCC remains a major challenge, ranking 4th in cancer incidence and 3rd in cancer mortality2. The primary goal of managing HCC is to achieve complete resection of the tumor while preserving liver function and minimizing complications, particularly in cases involving tumors adjacent to major vascular structures
Managing HCC becomes particularly complex when tumors are located near vital hepatic structures. The close proximity to these critical structures significantly complicates surgical intervention, necessitating a strategic approach to treatment. The challenges are exacerbated by risks of intraoperative bleeding, incomplete resection, and postoperative complications, highlighting the need for innovative surgical techniques and comprehensive preoperative management
Recent advancements in multidisciplinary treatment strategies, including targeted therapy, immunotherapy, and hepatic arterial infusion chemotherapy (HAIC), have shown promise in managing such challenging cases3. These therapies aim to reduce tumor size and improve surgical outcomes, making previously inoperable tumors amenable to resection4,5. In this context, the concept of the Laennec capsule, which focuses on precise anatomical dissection within the hepatic capsule, provides a framework for performing complex liver surgeries with improved precision and safety6,7.
This paper presents a patient with stage IB HCC, where neoadjuvant therapy comprising targeted therapy, immunotherapy, and HAIC successfully reduced the tumor size. Following this multimodal treatment, a laparoscopic anatomical right anterior sectionectomy was performed using the Laennec capsule concept. This approach enabled meticulous dissection of the right anterior branch of the portal vein, middle hepatic vein, and right hepatic vein, facilitating a successful resection with clear margins. The overall goal of this method is to integrate advanced neoadjuvant therapies with minimally invasive surgical techniques to achieve safe and effective resections of complex HCC cases, particularly those involving tumors closely associated with critical vascular structures.
The integration of advanced therapeutic modalities and innovative surgical techniques underscores progress in managing complex HCC cases, offering patients enhanced surgical outcomes and improved prognoses. Compared to conventional approaches, this combined strategy offers enhanced safety, reduced invasiveness, and improved long-term prognosis, providing a promising pathway for addressing high-risk HCC cases involving complex vascular anatomy.
CASE PRESENTATION:
The patient, a 75-year-old female, presented with a recent diagnosis of a liver tumor. A CT scan performed at an external hospital revealed a space-occupying lesion in the S8 segment, raising concerns about primary hepatocarcinoma. No significant family history of liver disease or cancer was reported. The patient was a non-smoker with no history of alcohol consumption. The patient was retired and lived in an urban area with access to healthcare facilities. No history of chronic liver diseases such as hepatitis or cirrhosis. The patient reported hypertension managed with medication and no history of diabetes or cardiovascular disease. No previous abdominal surgeries. The patient was asymptomatic, with no complaints of abdominal pain, jaundice, weight loss, or fatigue. Physical examination showed abdomen soft and non-tender, no palpable masses or organomegaly, and no signs of ascites or peripheral edema. The patient had not undergone any treatmentsprior to this admission.
Diagnosis, Assessment, and Plan:
The initial diagnosis of hepatocellular carcinoma (HCC) was made based on imaging findings and elevated alpha-fetoprotein (AFP) levels. The patient was staged as IB (pT1N0M0) according to the AJCC 8th Edition guidelines8. A treatment plan was established to include two cycles of neoadjuvant therapy, consisting of targeted therapy, immunotherapy, and hepatic arterial infusion chemotherapy (HAIC), to reduce tumor size and ensure operability. The patient was then scheduled for laparoscopic anatomical right anterior sectionectomy. After physical examination, the blood pressure was 130/80 mmHg, heart rate: 75 bpm, respiratory rate: 18 breaths/min, and temperature: 36.8 °C. The abdomen showed no visible distension or abnormal vascular patterns, and the liver and spleen were not palpable. No signs of cachexia or malnutrition were found. Skin and sclera were non-icteric. No spider angiomas or palmar erythema were observed.
Prior to the surgery, the patient provided written informed consent. The surgical procedure was approved by the institutional review board at Dongguan Bin-Hai-Wan Central Hospital.
1. Preoperative preparation
2. Surgical technique
3. Postoperative procedures
For the protocol described here, the patient, a 75-year-old asymptomatic female, presented with an incidentally detected liver mass. Her medical and surgical history was unremarkable, except for hypertension. Physical examination and vital signs were within normal limits. Further diagnostic evaluations, including imaging and laboratory tests, were conducted to confirm the diagnosis and plan treatment.
On April 23, 2023, further CT and EOB-MR scans confirmed a tumor located in the S8 segment, a...
This paper demonstrates the efficacy of a multimodal treatment approach for a patient with stage IB hepatocellular carcinoma (HCC; AJCC staging: T1bN0M0). The tumor, initially measuring 6.5 cm x 5.5 cm, was closely associated with critical vascular structures, including the second hepatic hilum, inferior vena cava, right hepatic vein, middle hepatic vein, right anterior branch of the portal vein, right posterior branch of the portal vein. Given the tumor's challenging location, a comprehensive treatment strategy was ...
The authors have nothing to disclose.
This study was supported by the Guangdong Medical Science and Technology Research Fund (Grant No. B2022197).
Name | Company | Catalog Number | Comments |
Absorbable Suture (Vicryl) | Johnson & Johnson | V-348 | |
Anesthesia Gas (N2O + O2) | Airgas | N2O/O2 | |
General Anesthesia Drugs | Roche | Propofol | |
Non-absorbable Suture (Prolene) | Ethicon | PROLENE 8698 | |
Povidone Iodine Solution | Betadine | BP-500 | |
Surgical Forceps | Surgical Instruments | SIC-925 | |
Surgical Scissors | Aesculap | KLS Martin 5245 | |
Surgical Sterile Drapes | 3M | Surgical Drapes | |
Titanium Clips | Medtronic | Endo GIA | |
Ultrasonic Scalpel | Ethicon | Harmonic ACE+ |
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