This work was supported by grants from the Science and Technology Project of Guangzhou City (202102010090) and the Guangzhou Municipal Health and Family Planning Commission (grant No.20201A001086 to Dr. Tang).

The procedure was reviewed and approved by the Clinical Research and Application Ethics Committee of the Second Affiliated Hospital of Guangzhou Medical University. The content and methods of the research are in line with medical ethics norms and requirements. The patient was informed of the purpose, background, process, risks, and benefits of the study prior to surgery. The patient understood that participation in this study was voluntary and signed informed consent.
1. Patient positioning, instruments, and port placement
<ol>
	<li>Place the patient in the supine and 30&#176; reverse Trendelenburg position on the operating table, and subsequently tilt 30&#176; to the right during the procedure, with the surgeon performing from the right side.</li>
	<li>Use the five-port technique during the procedure, with three 10 mm trocars, one 5 mm trocar, and one 12 mm trocar for retraction and specimen retrieval. Then, assemble the following hemostatic devices: 30&#176; laparoscope, laparoscopic ultrasonography device, and basic laparoscopic instruments, including a single lumen catheter, a harmonic scalpel, a monopole electrocoagulator, a vascular clip, and a powered endoscopic cutter stapler (see Table of Materials).</li>
	<li>Administer the patient a combination of intravenous and inhalation anesthesia by giving propofol 150 mg, sufentanil 15 ug, and rocuronium bromide 50 mg intravenously, followed by endotracheal intubation 7.5 F after 90 s. 
	NOTE: The selection of the anesthetic agents and the application of intravenous and inhalation anesthesia are decided and performed by the anesthetist on a case-to-case basis.
	<ol>
		<li>During the parenchymal transection, lower the central venous pressure by 3-5 cm H2O to reduce hepatic venous bleeding while limiting the fluid replacement as much as possible. Place a lumen catheter and nasogastric tube (see Table of Materials) in the bladder and stomach for urinary volume recording and decompression.</li>
	</ol>
	</li>
	<li>Routinely place a preoperative arterial line and a central venous (internal jugular vein) catheter. Use a 10 mm trocar for the observation port 2 cm below the umbilicus. Then, establish pneumoperitoneum by insufflating carbon dioxide, and maintain the intra-abdominal pressure at 12-14 mmHg (1 mmHg, 1/4 0.133 kPa).</li>
	<li>Place the other four trocars in the following locations: the 5 mm trocar in the right anterior axillary line, the 12 mm trocar in the right midclavicular line under the costal margin, the 10 mm trocar in the left anterior axillary line, and the 10 mm trocar in the left midclavicular line under the costal margin (Figure 2).</li>
</ol>
2. Surgical technique
<ol>
	<li>Pull the fundus of the gallbladder upward, and use a harmonic scalpel (see Table of Materials) for Calot&#39;s triangle18&#160;dissociation. Take care to ligate the cystic duct and artery with medium-sized hemostatic clips, do not cut the gallbladder, and leave the gallbladder in situ primarily (Figure 3).</li>
	<li>Segment the round and falciform ligaments with the harmonic scalpel. Separate the left coronary and triangular ligaments carefully, avoiding injury to the adjacent phrenic vein branches (Figure 4). Then, incisethe hepatogastric ligaments medially 10 mm into the lesser sac.</li>
	<li>Access from left to right behind the hepatoduodenal ligament through a sling removed from the attached 14 F single-lumen catheter to prepare for hepatic inflow occlusion (Figure 5).</li>
	<li>After ligating the left hepatic artery with medium-sized vascular clips, ensure that the first porta hepatis has been blocked with the single-lumen catheter to prevent unexpected bleeding during the mobilization of the left hepatic pedicle.
	<ol>
		<li>Gently lift the inferior edge of the liver, free the left Glissonean pedicles by the gap of the Laennec membrane19 and Hilar plate20 (Figure 6), and then prepare a tourniquet system to block the left hepatic inflow by inserting an 8 F single lumen catheter through the left Glissonean pedicle21 (Figure 7).</li>
	</ol>
	</li>
	<li>After releasing the first porta hepatis, block the left hepatic pedicle by clamping the single lumen catheter with a hemostatic clip (Figure 8), which will be stapled after parenchyma transection. Determine the border between the left and right hepatic lobes by identifying ischemia of the left hepatic lobe.
	<ol>
		<li>Following the dividing line, seek and mark the projection positions of the middle hepatic veins with laparoscopic ultrasonography. Pay attention to mapping the location and trajectories of the vital intrahepatic vessels, especially those located on the expected transverse plane of the liver parenchyma (Figure 9). 
		NOTE: In this study, the ultrasound was set to color Doppler flow image (CDFI) mode, and the thin-walled vessel flowing into the inferior vena cava in the same direction as the long axis of the ultrasound probe was judged to be the MHV. Moreover, it was also located near the dividing line.</li>
	</ol>
	</li>
	<li>Mark the parenchymal transection line with an electric hook along the demarcation line on the liver surface (Figure 10). Ask the assistant to drag the fundus of the gallbladder and transect the parenchyma from the foot side to the head side along the middle hepatic vein using an ultrasonic scalpel (Figure 11).
	<ol>
		<li>Trigger the ultrasonic scalpel early to effectively reduce hepatic parenchymal bleeding, and do not clamp the tip of the scalpel to avoid vessel damage. Secure or suture the large intrahepatic vessels and bile ducts found during the parenchymal resection with 2-0 sutures if necessary.</li>
	</ol>
	</li>
	<li>Expose the vascular pedicles inflowing into segments 4a/4b and the left hepatic vein further up in the cutting line (Figure 12). Then, expose the whole MHV and its tributaries fully, and dissect the roots of the LHV and MHV later (Figure 13). Lastly, staple the inflow and outflow vessels with the powered plus stapler when exposed.</li>
	<li>Once the liver specimens have been isolated from the remaining right hepatic lobe, conduct a hemostasis and bile leakage examination along the cut surface before suturing.
	<ol>
		<li>Use monopole electrocoagulation (see Table of Materials) for hemostasis when bleeding spots are found on the cut surface (Figure 14). Wrap the resected left hepatic lobe (Figure 15) in a plastic bag, and take it out through a 4 cm long incision in the lower abdomen, followed by the placement of two drainage tubes.</li>
	</ol>
	</li>
</ol>
3. Postoperative nursing
<ol>
	<li>On the first postoperative day, discontinue the nasogastric tube, and give the patient a liquid diet.</li>
	<li>Remove the Foley catheter on postoperative day 2, and assist the patient in getting out of bed for daily activities.</li>
	<li>Finally, when the drainage is less than 50 mL per day, remove the two drainage tubes on the fourth and fifth days, respectively. Ask the patient to return to the hospital for a follow-up examination 1 month later.</li>
</ol>

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<li>Zhang, Y. P., Shi, N., Jian, Z. X., Jin, H. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Research+progression+and+application+of+Laennec+capsule+in+liver%5BTitle%5D)+AND+%22Zhonghua+Wai+Ke+Za+Zhi%22%5BJournal%5D)">Research progression and application of Laennec capsule in liver.</a> Zhonghua Wai Ke Za Zhi. 58 (8), 646-648 (2020).</li>
<li>Yu, H. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Identification+of+the+anterior+sectoral+trunk+with+particular+reference+to+the+hepatic+Hilar+plate+and+its+clinical+importance%5BTitle%5D)+AND+%22Surgery%22%5BJournal%5D)">Identification of the anterior sectoral trunk with particular reference to the hepatic Hilar plate and its clinical importance.</a> Surgery. 149 (2), 291-296 (2011).</li>
<li>Takasaki, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Hepatic+resection+using+Glissonean+pedicle+transection%5BTitle%5D)+AND+%22Nihon+Geka+Gakkai+Zasshi%22%5BJournal%5D)">Hepatic resection using Glissonean pedicle transection.</a> Nihon Geka Gakkai Zasshi. 99 (4), 245-250 (1998).</li>
<li>Zhou, X. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Micrometastasis+in+surrounding+liver+and+the+minimal+length+of+resection+margin+of+primary+liver+cancer%5BTitle%5D)+AND+%22World+Journal+of+Gastroenterology%22%5BJournal%5D)">Micrometastasis in surrounding liver and the minimal length of resection margin of primary liver cancer.</a> World Journal of Gastroenterology. 13 (33), 4498-4503 (2007).</li>
<li>Makuuchi, M., Hasegawa, H., Yamazaki, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Ultrasonically+guided+subsegmentectomy%5BTitle%5D)+AND+%22Surgery%2C+Gynecology+and+Obstetrics%22%5BJournal%5D)">Ultrasonically guided subsegmentectomy.</a> Surgery, Gynecology and Obstetrics. 161 (4), 346-350 (1985).</li>
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<li>Yamazaki, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+the+outcomes+between+anatomical+resection+and+limited+resection+for+single+hepatocellular+carcinomas+no+larger+than+5+cm+in+diameter%3A+A+single-center+study%5BTitle%5D)+AND+%22Journal+of+Hepato-Biliary-Pancreatic+Sciences%22%5BJournal%5D)">Comparison of the outcomes between anatomical resection and limited resection for single hepatocellular carcinomas no larger than 5 cm in diameter: A single-center study.</a> Journal of Hepato-Biliary-Pancreatic Sciences. 17 (3), 349-358 (2010).</li>
<li>Yan, Y., Cai, X., Geller, D. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+liver+resection%3A+A+review+of+current+status%5BTitle%5D)+AND+%22Journal+of+Laparoendoscopic+%26+Advanced+Surgical+Techniques+A%22%5BJournal%5D)">Laparoscopic liver resection: A review of current status.</a> Journal of Laparoendoscopic & Advanced Surgical Techniques A. 27 (5), 481-486 (2017).</li>
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<li>Kang, W. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+results+of+laparoscopic+liver+resection+for+the+primary+treatment+of+hepatocellular+carcinoma%3A+Role+of+the+surgeon+in+anatomical+resection%5BTitle%5D)+AND+%22Surgical+Endoscopy%22%5BJournal%5D)">Long-term results of laparoscopic liver resection for the primary treatment of hepatocellular carcinoma: Role of the surgeon in anatomical resection.</a> Surgical Endoscopy. 32 (11), 4481-4490 (2018).</li>
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</ol>

The authors have no conflicts of interest or financial ties to disclose.

Anatomic hepatectomy is a procedure that can simultaneously remove the lesion and the liver segments along with the corresponding veins and has been considered an ideal method for treating liver cancer23,24,25,26. With technological innovation, anatomic liver resection with laparoscopic technology has developed rapidly as an alternative to conventional open liver resection and is now widely acc...

Hepatocellular carcinoma is a common cancer; it is the sixth most common neoplasm in adults and the third leading cause of cancer death worldwide, and its incidence is predicted to rise in the future1. Surgical resection, ablative electrochemical therapy, transarterial chemoembolization, systemic therapy such as sorafenib, and transplantation have been reported to be effective treatment modalities for liver cancer2,3. Of these options, surgical resection of hepatocellular carcinoma (HCC) is considered the primary curative treatment since the tumor can be completely removed rather than limited4.
Laparoscopic surgery, a minimally invasive technique with fewer perioperative complications compared to open resection5, has made great progress worldwide and has steadily become an important surgical method for liver surgery6,7,8. However, in laparoscopic liver resection, the surgeon&#39;s inability to recognize the tumor margins under direct vision and the fear of not being able to ensure laparoscopic hemostasis have discouraged most liver surgeons from attempting this demanding procedure. In 1960, Lin et al. reported a case of right hepatic lobectomy with intrahepatic portal vein pedicle ligation9. In 1986, Takasaki also described Glisson&#39;s pedicle transect hepatectomy, named extrathecal dissection10. In 1991, Reich et al. applied laparoscopic resection of benign liver tumors and completed the world&#39;s first laparoscopic hepatectomy11. Since then, anatomical hepatectomy has gradually entered the public view while providing technical support for laparoscopic hepatectomy. However, in the case in the present study, the lower end of the tumor reached the cystic plate, and simple traditional anatomic resection could not guarantee an R0 resection, but the management of such cases has rarely been reported in detail. In 1999, Neuhaus et al. proposed the principle of total portal vein resection, which proved to be a good prognostic indicator, increasing the chance of R0 resection12. Accordingly, with a new understanding of liver anatomy, we advanced a new approach called &#34;en bloc concept combined with anatomic resection&#34;, which is depicted in this video protocol.
In this study, the patient was a 67-year-old female admitted to our hospital in August 2021 with mild upper abdominal pain for 1 month. Her medical history was notable for hypertension and diabetes. Abdominal contrast-enhanced computed tomography revealed a mass with heterogeneous enhancement located at segment 4 of the liver, with a size of 247 mm x 54 mm x 50 mm. The lower end of the mass had reached the cystic plate, and the possibility of gallbladder invasion could not be ruled out (Figure 1). The Child-Pugh liver function13 was grade A, and the ICG clearance rate14,15 R15 was 5.1% (&#60;10%). The patient was classified as stage A according to the BCLC algorithm16 and stage IB according to the CNLC algorithm17. After a multidisciplinary meeting, it was decided that her treatment should be laparoscopic left lobe resection of the liver and cholecystectomy. The concept of en bloc resection combined with anatomic hepatic resection in laparoscopy was adopted to eliminate the enormous liver mass totally.

<table><tbody><tr><td>30&amp;deg; Laparoscopy</td><td>Olympus Corporation</td><td>CV-190</td><td></td></tr><tr><td>Harmonic Ace Ultrasonic Surgical Devices</td><td>Ethicon Endo-Surgery, LLC</td><td>&amp;nbsp;HAR36</td><td></td></tr><tr><td>Laparoscopic ultrasonography</td><td>Hitachi</td><td>Arietta 60</td><td></td></tr><tr><td>Monopole electrocoagulation</td><td>Kangji Medical</td><td>/</td><td></td></tr><tr><td>Nasogastric tube</td><td>Pacific Hospital Supply Co. Ltd</td><td>I02705</td><td></td></tr><tr><td>Powered plus stapler</td><td>Ethicon Endo-Surgery, LLC</td><td>PSEE60A</td><td></td></tr><tr><td>Single lumen ureter</td><td>Well Lead Medical CO, LTD</td><td>14F,8F</td><td></td></tr><tr><td>Trocar</td><td>Surgaid Medical</td><td>NPCM-100-1-10</td><td></td></tr><tr><td>Vascular clips</td><td>Teleflex Medical</td><td>544243</td><td></td></tr></tbody></table>

application of the en bloc concept combined with anatomic resection in laparoscopic hepatectomy

Laparoscopic hepatectomy has been reported in many studies, and it is the mainstream method of liver resection. In some particular cases, such as when there are tumors adjacent to the cystic bed, surgeons cannot palpate the surgical margins through the laparoscopic approach, which leads to uncertainty about R0 resection. Conventionally, the gallbladder is resected first, and the hepatic lobes or segments are resected second. However, tumor tissues can be disseminated in the above cases. To address this issue, based on the recognition of the porta hepatis and intrahepatic anatomy, we propose a unique approach to hepatectomy combined with gallbladder resection by en bloc anatomic resection in situ. Firstly, after dissecting the cystic duct, without cutting the gallbladder primarily, the porta hepatis is pre-occluded by the single lumen ureter; secondly, the left hepatic pedicle is made free by the gap of the Laennec membrane and Hilar plate; thirdly, the assistant is asked to drag the fundus of the gallbladder, and the liver parenchyma tissue is resected using a harmonic scalpel along the ischemia line on the liver surface and intraoperative ultrasound. The whole middle hepatic vein (MHV) and its tributaries appear completely; lastly, the left hepatic vein (LHV) is disconnected, and the specimen is taken out from the abdominal cavity. The tumor, gallbladder, and other surrounding tissues are resected en bloc, which meets the tumor-free criterion, and a wide incisal margin and R0 resection are achieved. Therefore, the laparoscopic hepatectomy with the combination of the en bloc concept and anatomic resection is a safe, effective, and radical method with low postoperative recurrence and metastasis.

The duration of the operation was 255 min, no complications were observed during the operation, and the estimated blood loss was less than 20 mL. The operation was not converted to open surgery, and no postoperative complications were seen. Liver segment 2, liver segment 3, and liver segment 4 (including the gallbladder) were resected anatomically, and the MHV as well as its tributaries (V5v, ventral branch of the fifth segment of the hepatic vein; V8v, ventral branch of the eigth segment of the hepatic vein) were comple...

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Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy

Numerous studies have demonstrated the advantages of anatomic resection. Nonetheless, whether anatomic resection can increase R0 resection rates remains controversial. Consequently, the present study describes an innovative procedure involving the en bloc concept combined with anatomic resection in laparoscopic hepatectomy, which can reduce postoperative recurrence and metastasis.

Laparoscopic hepatectomy has been reported in many studies, and it is the mainstream method of liver resection. In some particular cases, such as when ...

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Research

JoVE Journal

Cancer Research

1.1K Views.  the Second Affiliated Hospital of Guangzhou Medical University. Met deze minimaal invasieve methode is het verkrijgen van een breed scala aan negatieve marges gemakkelijker en wordt de verspreiding van tumorweefsel vermeden. Deze methode helpt bij het maximaliseren van R0-resectie en het voorkomen van perioperatieve complicaties. Deze techniek kan worden gebruikt bij laparoscopische leverresectieoperaties met resectie van vier tot vijf segmenten.Omdat deze minimaal invasieve chirurgische methode ervaring met open operaties vereist, wordt een geschi...

Video: Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy

Application of Hemostatic Devices in Laparoscopic Hepatectomy

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. Despite its non-invasive aspect, bleeding and bile leakage occur in liver parenchyma tissue resection during the operation or in the post-operation period, indicating the requirement for high-grade hemostatic devices, such as ultrasonic surgical aspiration, bipolar electrocoagulation, etc. The lack of availability of these high-grade hemostatic devices prevents laparoscopic hepatectomy from becoming a generalized procedure in basic medical organizations. In view of the situation mentioned above, a suite of simple and easy hemostatic devices is developed in this protocol, which includes a harmonic scalpel, monopole electrocoagulation, and a single lumen catheter, to innovatively perform liver parenchyma tissue resection. First of all, the porta hepatis or hepatic pedicle is occluded intermittently by a single lumen catheter, followed by clamping for 15 min and releasing for 5 min. Subsequently, using the harmonic scalpel, clamping and crushing of the liver are done to cut off the hepatic parenchyma tissue and to reveal the intrahepatic arteries, veins, and bile ducts. Lastly, the bleeding spots are coagulated by using monopole electrocoagulation at each spot. Intrahepatic pipeline structures are then visible by using these methods, which could stop bleeding easily, reduce the incidence rate of bile leakage, and improve the safety and feasibility of laparoscopic hepatectomy. Therefore, the simple and easy hemostatic devices shown here are suitable for conducting procedures in primary medical institutions.

High-grade hemostatic devices are essential for laparoscopic hepatectomy. However, these devices are not generalized in basic medical organizations. Therefore, a suite of simple and easy hemostatic devices is shown in this article, which can make the laparoscopic hepatectomy easier to perform.

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. ...

Laparoscopic Anatomical Hepatectomy Using Takasaki's Approach and Indocyanine Green Fluorescence Navigation

Laparoscopic anatomical liver resection is a standard treatment for liver cancer. Segmental resection of S4/5/7/8 is complex and lacks standardized procedures, leading to common complications. Innovative techniques are essential for enhancing safety and outcomes. A 45-year-old male with a history of hepatitis B, Child-Pugh Class A liver function, performance status (PS) score 0, and alpha-fetoprotein (AFP) level of 198.3 ng/mL was diagnosed with a 4 cm &#215; 5 cm &#215; 5 cm mass in S4/7/8, indicating primary hepatocellular carcinoma (HCC), closely associated with the middle and right hepatic veins (BCLC A). The 15-min retention rate of indocyanine green (ICG) was 7.8%. The standard liver volume (SLV) was 1073 mL, and the actual liver volume was 1345 mL. We performed laparoscopic resection of segments S4/5/8 and partial S7, resecting the middle hepatic vein (MHV) while preserving the right hepatic vein (RHV) because MHV was so closed with the tumor. The future liver remnant (FLR) was 590 mL, with an FLR/SLV ratio of 55%. The surgical procedure utilized Takasaki's approach to block the right anterior hepatic pedicle and fluorescence staining to identify the transection line. The operation lasted 205 min with an estimated blood loss of 150 mL. The patient experienced no postoperative complications and was discharged on the sixth day. Histopathology confirmed hepatocellular carcinoma with clear resection margins. Takasaki's approach, combined with ICG fluorescence navigation, significantly improves laparoscopic anatomical hepatectomy. This technique enhances visualization, reduces complications, and offers a new standard for complex liver resections.

Here, we present a protocol for laparoscopic anatomical hepatectomy using Takasaki's approach and indocyanine green fluorescence navigation in S4/5/7/8 resection.

Laparoscopic anatomical liver resection is a standard treatment for liver cancer. Segmental resection of S4/5/7/8 is complex and lacks standardized ...

Application of Laparoscopic Hepatectomy Combined with Intraoperative Microwave Ablation in Colorectal Cancer Liver Metastasis

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to be maintained during laparoscopic hepatectomy, with a residual liver volume of &gt;40% in cirrhotic patients and &gt;30% in non-cirrhotic patients. The high incidence of complications such as bleeding, bile leakage, or liver failure due to the exposure and difficulty of the resection of specific liver segments such as S2 and S7 reduces the success rate of liver resection. At present, microwave ablation is mainly applied in the treatment of liver metastasis using a percutaneous approach, which makes it difficult to identify hidden parts or small lesions. For some liver segments, the percutaneous puncture of liver segment 7 (S7) is likely to pass through the thoracic cavity, and the percutaneous puncture of liver segment 2 (S2) adjacent to the diaphragm is likely to injure the diaphragm and heart; these issues restrict the application of percutaneous ablation in colorectal cancer liver metastasis. Considering multiple lesions, laparoscopic microwave ablation combined with hepatectomy was performed in this study. The location of the lesions was determined by contrast-enhanced ultrasound under laparoscopy, and small lesions that were difficult to detect before the operation were identified. For the scattered lesions, which had diameters less than 3 cm and were difficult to resect, ablation was adopted to substitute hepatectomy. This technique helped to more explicitly locate the tumors, simplified the operation procedures, reduced the risk of complications such as bleeding and bile leakage, shortened the operation time, accelerated the postoperative recovery, significantly improved the success rate of operation, and enhanced the clinical prognosis of colorectal cancer liver metastasis by surgical resection.

This protocol describes the laparoscopic resection of colorectal cancer liver metastases combined with ultrasound-guided microwave ablation. This technique can safely, effectively, and accurately treat refractory liver metastases &lt;3 cm, reduce postoperative complications, and accelerate the postoperative rehabilitation of patients.

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to ...

Medicine

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to the anatomical characteristics of the liver, with intraoperative hemorrhage being a primary concern. Intraoperative blood loss is the leading cause of conversion to open surgery; therefore, effective management of bleeding and hemostasis is crucial for a successful LAH.
The two-surgeon technique is proposed as an alternative to the traditional single-surgeon approach, with potential benefits in reducing intraoperative bleeding during laparoscopic hepatectomy. However, there remains a lack of evidence to determine which mode of the two-surgeon technique yields superior patient outcomes. Besides, to our knowledge, the LAH technique, which involves the use of a cavitron ultrasonic surgical aspirator (CUSA) by the primary surgeon while an ultrasonic dissector by the second surgeon, has been rarely reported before.
Herein, we present a modified, two-surgeon LAH technique, wherein one surgeon employs a CUSA while the other uses an ultrasonic dissector. This technique is combined with a simple extracorporeal Pringle maneuver and low central venous pressure (CVP) approach. In this modified technique, the primary and secondary surgeons utilize a laparoscopic CUSA and an ultrasonic dissectorconcurrently to achieve precise and expeditious hepatectomy. A simple extracorporeal Pringle maneuver, combined with the maintenance of low CVP, is employed to regulate the hepatic inflow and outflow in order to minimize intraoperative bleeding. This approach facilitates the attainment of a dry and clean operative field, which allows for the precise ligation and dissection of blood vessels and bile ducts. The modified LAH procedure is simpler and safer due to its effective control over bleeding as well as the seamless transition between the roles of primary and secondary surgeons. It holds great promise for future clinical applications.

Here, we present a protocol to perform a modified laparoscopic anatomic hepatectomy using improved techniques and instruments.

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to ...

Advancing LRPS: Optimal Techniques for Challenging Liver Resections

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.

Here, we present a protocol to perform laparoscopic right posterior sectionectomy, focusing on two key aspects: the intrahepatic Glissonian approach for inflow control and a parenchymal transection technique using an ultrasonic surgical aspirator.

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver ...

Laparoscopic Sectionectomy Using Ligamentum Teres for Bloodless Hepatectomy

Laparoscopic Left Lateral Sectionectomy: Guided by the Ligamentum Teres Hepatis and the Umbilical Fissure Vein

Laparoscopic left lateral sectionectomy (LLLS), a mainstream procedure in liver surgery, often utilizes controlled low central venous pressure (CLCVP) to reduce bleeding in the hepatic venous system. However, anesthesiologists may avoid the use of CLCVP in patients with concurrent cardiovascular and cerebrovascular diseases to prioritize the maintenance of vital organ perfusion. In this report, we present an LLLS guided by the ligamentum teres hepatis (LTH) for dissection of the Glissonian pedicles for segments 2/3 outside the liver, followed by hepatic parenchymal dissection along the falciform ligament and umbilical fissure vein (UFV) while approaching the left hepatic vein root. Guided by LTH and UFV, this LLLS procedure effectively controlled intraoperative bleeding, even in the absence of CLCVP. Additionally, hepatectomy guided by extrahepatic and intrahepatic anatomical landmarks prevents loss of direction during liver dissection and ensures precise hepatic resection. These attributes suggest that the potential benefits extend beyond patients with cardiovascular or cerebrovascular conditions, making it applicable in a wide range of LLLS cases.

Author Spotlight: Advancing Hepatobiliary and Pancreatic Tumor Treatment with Minimally Invasive Surgical Techniques

Laparoscopic left lateral sectionectomy guided by the ligamentum teres hepatis and umbilical fissure vein effectively controls intraoperative bleeding even without controlled low central venous pressure and prevents loss of direction during parenchymal dissection.

Laparoscopic left lateral sectionectomy (LLLS), a mainstream procedure in liver surgery, often utilizes controlled low central venous pressure (CLCVP) to ...

Laparoscopic Left Approach Resection of the Caudate Lobe

Laparoscopic caudate lobectomy (LCL) is one of the most challenging types of laparoscopic liver resections. The main difficulty lies in the deep anatomical position of the caudate lobe, which is closely adjacent to the first and second hepatic ports and the inferior vena cava, increasing the risk of major bleeding during surgery. In addition to a thorough understanding of the anatomy of the caudate lobe tumor, comprehensive imaging assessment, and three-dimensional reconstruction, the flexible choice of surgical approach is also key to reducing surgical difficulty and improving safety. We perform laparoscopic caudate lobectomy using a left-sided approach, especially when the tumor is located in the area of the caudate lobe close to the inferior vena cava. This method avoids the step of splitting the liver substance to expose the field of view required by the traditional anterior approach, with the advantages of larger operating space and shorter operation time. At the same time, combined with preoperative three-dimensional reconstruction technology, we have significantly reduced the risk of damaging important blood vessels and increased the success rate of resection of tumors in the caudate lobe.

Here, we present a surgical protocol describing the laparoscopic resection of a tumor situated near the paracaval portion within the caudate lobe, utilizing a left-sided approach.

Laparoscopic caudate lobectomy (LCL) is one of the most challenging types of laparoscopic liver resections. The main difficulty lies in the deep ...

Laparoscopic Left Hemihepatectomy Combined with Caudate Lobe Resection

Intrahepatic cholangiocarcinoma (ICC) is the common malignant tumor of the liver. Radical surgical resection is the mainstay of potentially curative treatment for ICC. Anatomical liver resection for ICC in the caudate lobe is one of the most difficult liver resections. Because the tumor is located deep and easily invades surrounding blood vessels, such as the left hepatic pedicle, right hepatic pedicle, and middle hepatic vein. Laparoscopic anatomic hepatectomy of the caudate lobe not only ensures a negative incision margin but also offers a more minimally invasive approach for patients. This technique is poised to become the preferred choice for radical surgery of the caudate lobe in the future. In this surgical protocol, a 65-year-old male patient with intrahepatic cholangiocarcinoma (sized about 3.2&#160;&#215; 1.9 cm2) located in the left caudal lobe underwent laparoscopic left hemihepatectomy combined with caudate lobe resection successfully without any postoperative complications. Postoperative pathological examination showed a cholangiocarcinoma with a tumor thrombus visible in the vasculature. The patient was discharged on the 14th postoperative day. Laparoscopic left hemihepatectomy combined with caudate lobectomy for the treatment of caudate lobe ICC can be performed safely and does not add significantly to the morbidity or mortality of the procedure.

Intrahepatic cholangiocarcinoma of the caudate lobe is a challenge for many surgeons due to its unique location. Here, we present a protocol to show the step-by-step details of laparoscopic left hemihepatectomy combined with caudate lobe resection for cholangiocarcinoma.

Intrahepatic cholangiocarcinoma (ICC) is the common malignant tumor of the liver. Radical surgical resection is the mainstay of potentially curative ...

Laparoscopic Anatomical Resection of The Right Anterior Lobe Based on The Laennec Capsule Technique

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.

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 ...

Laparoscopic S7 Hepatectomy with Positive Fluorescence Staining

Laparoscopic liver resection for tumors located in the S7 segment of the liver typically adopts a traditional surgical approach. The main goal of this procedure is to accurately dissect the liver pedicle of the S7 segment. Dissecting the hepatic pedicle of the S7 segment along the hepatic hilum requires a relatively long path within the liver, which increases the risk of losing orientation and potentially injuring the adjacent hepatic pedicle of the S5 and S6 segments, thereby compromising the liver resection plane. A positive staining method was used to directly puncture the corresponding portal vein under ultrasound guidance (commonly for S7 and S8 segments) to specifically color the target liver segment, thereby avoiding extensive resection of the liver parenchyma, and reducing damage to the surrounding healthy liver tissue. However, the positive staining method requires a specific foundation in intraoperative procedures, which can be challenging for surgeons and has a certain learning curve. Currently, technologies such as three-dimensional reconstruction territory analysis, intraoperative ultrasound, and indocyanine green fluorescence imaging are popular and commonly used in laparoscopic liver resection. In this protocol, under laparoscopic ultrasound guidance, the tumor basin was punctured through the visceral and diaphragmatic surfaces of the liver to stain segment S7. Laparoscopic resection of segment S7 within the portal territory anatomic liver was successfully performed, further confirming the feasibility and advantages of positive fluorescence staining in laparoscopic liver resection at this stage.

The protocol demonstrates that, under laparoscopic ultrasound guidance, the S7 segment of the liver can be successfully stained by puncturing the visceral and diaphragmatic branches of the tumor, facilitating an anatomical hepatectomy of the S7 segment.

Laparoscopic liver resection for tumors located in the S7 segment of the liver typically adopts a traditional surgical approach. The main goal of this ...

Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy

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