This paper was supported by funding from the National Natural Science Foundation of China (82060454), the key research and development program of Jiangxi Province of China (20203BBGL73143), and the Jiangxi Province high-level and high-skill leading talent training project (G/Y3035).

The study follows the human research ethics committee of the Second Affiliated Hospital of Nanchang University. Written informed consent was obtained from the patient prior to surgery.
NOTE: The patient was a 65-year-old male presenting with a chief complaint of &#34;generalized jaundice and pruritus for 2 weeks&#34;. A computed tomography (CT) scan at an outside hospital revealed a perihilar bile duct mass with intrahepatic bile duct dilation. The surgical instruments and equipment used are listed in the Table of Materials.
1. Preoperative preparation
<ol>
	<li>Perform routine blood tests preoperatively, including complete blood count, liver and kidney function tests, coagulation profile, and serum tumor markers.
	<ol>
		<li>Draw blood samples, send them to the laboratory for various blood tests, and report the results. 
		NOTE: Liver function tests showed elevated total bilirubin (230.8 &#956;mol/L) and decreased albumin (35.7 g/L). Serum tumor marker tests revealed elevated carbohydrate antigen carbohydrate antigen 199 (184.46 U/mL)4,12.</li>
	</ol>
	</li>
	<li>Perform preoperative electrocardiogram (ECG), abdominal CT, magnetic resonance imaging (MRI) of the abdomen, chest CT, and other relevant examinations4,12. 
	NOTE: In this study, the patient underwent an abdominal CT scan with and without contrast in the radiology department. The scan showed a mass in the perihilar region without involvement of surrounding vessels, suggesting cholangiocarcinoma with obstruction (Figure 1). MRI with and without contrast and magnetic resonance cholangiopancreatography demonstrated a mass in the perihilar bile duct and adjacent liver parenchyma with intrahepatic bile duct dilatation and enlarged perihilar lymph nodes, indicating a neoplastic lesion (Figure 1).</li>
</ol>
2. Surgical procedure
<ol>
	<li>Administer general anesthesia with tracheal intubation, intravenous and inhalational agents. Position the patient supine with the head elevated and legs apart. Perform routine disinfection using povidone-iodine solution. 
	NOTE: The primary surgeon stands on the patient&#39;s right side, the assistant on the left side, and the camera holder between the patient&#39;s legs (Figure 2).</li>
	<li>Make a longitudinal incision of approximately 1 cm at the umbilicus, insert a Veress needle, and insufflate CO2 to maintain an intra-abdominal pressure of 12 mmHg. Insert a 10 mm trocar and a 30&#176; laparoscope. After confirming no distant metastasis via laparoscopy, place the surgical trocars as shown in Figure 2.</li>
	<li>Dissect the cystic artery and cystic duct, then proceed with the retrograde removal of the gallbladder. Use an ultrasonic scalpel to dissect, mobilize, and suspend the common hepatic artery (CHA), gastroduodenal artery (GDA), proper hepatic artery (PHA), and the left hepatic arteries (LHA) (giving off the middle hepatic artery (MHA)) and right hepatic arteries (RHA). Ligate and divide the right gastric arteries (RGA) and LHA (Figure 3).</li>
	<li>Transect the common bile duct (CBD) at the superior border of the pancreas and send the distal margin for frozen section pathology to confirm negative margins.</li>
	<li>Use an ultrasonic scalpel to dissect, mobilize, and suspend the portal vein (PV). Remove the extrahepatic bile duct and lymph node groups 8, 12, and 13 en bloc along the PV towards the hepatic hilum, achieving skeletonization of the hepatoduodenal ligament.</li>
	<li>Ligate and divide the left branch of portal vein (LPV) and caudate lobe portal vein branches.
	<ol>
		<li>Dissect the left hepatic ligaments and divide the short hepatic veins of the caudate lobe, clearly delineating the demarcation line (ischemic line) between the right and left liver lobes.</li>
		<li>After marking the demarcation line, confirm that the fluorescence boundary matched the ischemic line using fluorescence imaging (Figure 4, and Figure 5). 
		NOTE: A negative staining method is used here, with indocyanine green administered via peripheral intravenous injection at a dose of 0.25 mg13,14.</li>
	</ol>
	</li>
	<li>Intermittently occlude the main PV using the Pringle maneuver15. Use an ultrasonic scalpel to transect the liver parenchyma along the demarcation line, then along the plane of the middle hepatic vein (MHV), ensuring to divide its V4b and V4a branches. 
	NOTE:&#160;Patients with a positive liver margin may consider undergoing expanded left hepatectomy (LH), which involves the complete resection of the main trunk of the MHV and the left portions of segments 5 and 8. This approach may improve survival rates16.&#160; &#160; &#160; &#160; &#160; &#160; &#160; &#160;&#160;</li>
	<li>Transect the right hepatic duct approximately 1 cm from the tumor and send the proximal margin for frozen section pathology to confirm negative margins.
	<ol>
		<li>Perform intraoperative frozen section analysis of the proximal hepatic duct margin multiple times as needed to ensure an R0 resection. If the right hepatic duct is extensively divided, consider bile duct reconstruction or double hepaticojejunostomy of the right anterior and right posterior bile ducts.</li>
	</ol>
	</li>
	<li>Transect the left hepatic vein (LHV) using an endoscopic linear cutter stapler (ENDO-GIA). Completely resect the left hemiliver and the entire caudate lobe, and place the specimen in a retrieval bag (Figure 6).</li>
	<li>Transect the jejunum approximately 20 cm distal to the ligament of Treitz. Elevate the distal loop posterior to the colon for an end-to-side anastomosis with the right hepatic duct, using continuous sutures for the anterior and posterior walls (Figure 7). Perform a side-to-side jejunojejunostomy approximately 45 cm distal to the right hepatic duct-jejunal anastomosis.</li>
	<li>Irrigate the abdominal cavity with sterile distilled water. Carefully inspect the surgical field for active bleeding, bile leaks, and gastrointestinal side branch injuries. Place drainage tubes in the left liver section and Winslow&#39;s foramen.</li>
	<li>Extend the umbilical incision by approximately 5 cm and dissect the abdominal wall layer by layer to retrieve the specimen. Verify the count of surgical instruments and gauze. Remove the trocars under direct vision. Close the abdominal wall incision with interrupted 2-0 absorbable sutures to complete the surgery.</li>
</ol>
3. Postoperative care
<ol>
	<li>Transport the patient safely back to the ward after the patient regains consciousness.</li>
	<li>Administer intravenous antibiotics, omeprazole, and nutritional support postoperatively.</li>
	<li>Start a liquid diet on the third postoperative day after the patient passes gas.</li>
	<li>Remove the abdominal drainage tubes on the 4th and 13th postoperative days.</li>
</ol>

<ol>
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The authors have nothing to disclose.

pCCA is a common malignant tumor of the bile ducts, with radical surgical resection being the only potential curative treatment2. Traditional radical surgery for pCCA typically requires an abdominal incision of 20&#8211;30 cm, resulting in significant surgical trauma. Large incisions often cause considerable postoperative pain, affecting patient comfort and recovery, thereby prolonging hospital stays5,6,7...

Perihilar cholangiocarcinoma (pCCA), also known as Klatskin tumor, was first described by Gerald Klatskin and is a malignant tumor that occurs in the bile duct epithelium at the confluence of the right and left hepatic ducts1. This disease is highly malignant and aggressive, often presenting with jaundice and cholangitis in advanced stages. Despite advancements in diagnosis and treatment, the prognosis for pCCA remains poor, with radical surgical resection still being the only potentially curative approach. Such surgeries typically involve extensive hepatectomy, bile duct resection, and regional lymphadenectomy2. The goal of surgery is to achieve an R0 resection, which significantly improves patient survival rates3,4. However, the complex anatomy of the hilar region and the tumor&#39;s proximity to vital vascular structures make these surgeries highly challenging.
In recent years, the advent of laparoscopic technology has revolutionized surgical oncology, offering potential advantages such as reduced perioperative complications, shorter hospital stays, and faster recovery5,6,7. Nevertheless, the application of laparoscopic surgery in pCCA, particularly for type IIIb cases, remains limited, with only a few reports available3,8. This is primarily due to the technical difficulty in achieving adequate margins and performing complex biliary and vascular reconstructions laparoscopically9. Current guidelines recommend left hemihepatectomy combined with total caudate lobectomy and standardized lymphadenectomy for resectable type IIIb pCCA4,10,11,12. However, evidence supporting the use of laparoscopic methods for this extensive surgery is still accumulating.
This study presents the complete laparoscopic radical resection of type IIIb pCCA. We aim to detail this surgery&#39;s techniques and key steps, including left hemihepatectomy, total caudate lobectomy, regional lymphadenectomy, and Roux-en-Y hepaticojejunostomy. By sharing this protocol, we hope to contribute to the evidence supporting the feasibility and safety of laparoscopic methods in the treatment of type IIIb pCCA, ultimately improving patient outcomes.

<table><tbody><tr><td>5-mm trocar</td><td>CANWELL MEDICAL Co., LTD</td><td>179094F</td><td>Sterile, ethylene oxide sterilized,&lt;br/&gt; disposable</td></tr><tr><td>12-mm trocar</td><td>CANWELL MEDICAL Co., LTD</td><td>NB12STF</td><td>Sterile, ethylene oxide sterilized,&lt;br/&gt; disposable</td></tr><tr><td>Absorbable Sutures</td><td>America Ethicon Medical Technology Co., LTD</td><td>W8557/W9109H/VCPB839D</td><td>Sterile, ethylene oxide sterilized,&lt;br/&gt; disposable</td></tr><tr><td>Alligaclip Absorbable Ligating Clip</td><td>Hangzhou Sunstone Technology Co., Ltd.</td><td>K12</td><td>Sterile, ethylene oxide sterilized,&lt;br/&gt; disposable</td></tr><tr><td>Endoscopic linear cutting stapler</td><td>America Ethicon Medical Technology Co., LTD</td><td>ECR60W/PSEE60A</td><td>Sterile, ethylene oxide sterilized,&lt;br/&gt; disposable</td></tr><tr><td>Non-absorbable polymer ligature clip</td><td>Greiner Bio-One Shanghai Co., Ltd.</td><td>0301-03M04/0301-03L04/0301-03ML02</td><td>Sterile, ethylene oxide sterilized,&lt;br/&gt; disposable</td></tr><tr><td>NonAbsorbable Sutures</td><td>America Ethicon Medical Technology Co., LTD</td><td>EH7241H/EH7242H</td><td>Sterile, ethylene oxide sterilized,&lt;br/&gt; disposable</td></tr><tr><td>Ultrasonic scalpel</td><td>America Ethicon Medical Technology Co., LTD</td><td>HARH36</td><td>Sterile, ethylene oxide sterilized,&lt;br/&gt; disposable</td></tr></tbody></table>

complete laparoscopic radical resection of perihilar cholangiocarcinoma type iiib

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With continuous advancements in laparoscopic techniques and instruments, laparoscopic radical surgery for pCCA is now considered technically safe and feasible. However, due to the high complexity of the surgery and the lack of evidence-based clinical support, laparoscopic radical surgery for type IIIb pCCA is performed only in a few large hepatobiliary centers. Current guidelines recommend left hemihepatectomy combined with total caudate lobectomy and standardized lymphadenectomy for resectable type IIIb pCCA. Therefore, in this article, we provide a detailed description of the surgical steps and technical points of complete laparoscopic left hemihepatectomy combined with total caudate lobectomy, regional lymphadenectomy, and right hepatic duct-jejunal Roux-en-Y anastomosis in patients with type IIIb pCCA, using fluorescence navigation technology to enhance surgical precision and safety. By adhering to standardized surgical procedures and precise intraoperative techniques, we offer an effective means to improve patient outcomes.

The surgery progressed smoothly, and intraoperative frozen section pathology showed negative margins at both the distal and proximal bile ducts. Throughout the procedure, the patient&#39;s vital signs remained stable, and anesthesia was effective. The operation lasted 360 min, with PV occlusion time totaling 60 min (15 min + 5 min &#215; 4 times). Intraoperative blood loss was 400 mL, and the patient received 2 units of leukocyte privative red blood cells and 600 mL of fresh frozen plasma. Postoperative flatus was observ...

Complete Laparoscopic Radical Resection of Perihilar Cholangiocarcinoma Type IIIb

Perihilar cholangiocarcinoma (pCCA) is a highly malignant and aggressive tumor, with radical resection being the only curative treatment available. With ...

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171 Views.  The Second Affiliated Hospital of Nanchang University. De reikwijdte van mijn onderzoek richt zich op de diagnose, chirurgische behandeling en postoperatieve zorg van lever- en pancreastumoren. De huidige technologieën zijn het enige dat in mijn vakgebied wordt onderzocht, waaronder moderne visualisatietechnologie, die helpt bij het plannen van precisiechirurgie en het begeleiden van operaties. Precisiegeneeskunde gebruikt genetische en moleculaire details om behandelingen voor elke patiënt te ontwerpen....

Video: Volledige laparoscopische radicale resectie van perihilair cholangiocarcinoom type IIIb

Laparoscopic Left Liver Sectoriectomy of Caroli's Disease Limited to Segment II and III

Caroli's disease is defined as a abnormal dilatation of the intra-hepatica bile ducts: Its incidence is extremely low (1 in 1,000,000 population) and in most of the cases the whole liver is interested and liver transplantation is the treatment of choice. In case of dilatation limited to the left or right lobe, liver resection can be performed. For many year the standard approach for liver resection has been a formal laparotomy by means of a large incision of abdomen that is characterized by significant post-operatie morbidity. More recently, minimally invasive, laparoscopic approach has been proposed as possible surgical technique for liver resection both for benign and malignant diseases. The main benefits of the minimally invasive approach is represented by a significant reduction of the surgical trauma that allows a faster recovery a less post-operative complications.
This video shows a case of Caroli s disease occured in a 58 years old male admitted at the gastroenterology department for sudden onset of abdominal pain associated with fever (>38C&deg; ), nausea and shivering. Abdominal ultrasound demonstrated a significant dilatation of intra-hepatic left sited bile ducts with no evidences of gallbladder or common bile duct stones. Such findings were confirmed abdominal high resolution computer tomography. 
Laparoscopic left sectoriectomy was planned. Five trocars and 30&deg; optic was used, exploration of the abdominal cavity showed no adhesions or evidences of other diseases.
In order to control blood inflow to the liver, vascular clamp was placed on the hepatic pedicle (Pringle s manouvre), Parenchymal division is carried out with a combined use of 5 mm bipolar forceps and 5 mm ultrasonic dissector. A severely dilated left hepatic duct was isolated and divided using a 45mm endoscopic vascular stapler. Liver dissection was continued up to isolation of the main left portal branch that was then divided with a further cartridge of 45 mm vascular stapler.
At his point the left liver remains attached only by the left hepatic vein: division of the triangular ligament was performed using monopolar hook and the hepatic vein isolated and the divided using vascular stapler.
Haemostatis was refined by application of argon beam coagulation and no bleeding was revealed even after removal of the vascular clamp (total Pringle s time 27 minutes).
Postoperative course was uneventful, minimal elevation of the liver function tests was recorded in post-operative day 1 but returned to normal at discharged on post-operative day 3.

This video presents a case of laparoscopic left liver sectoriectomy perfomed in a 53 year old man suffering from Caroli's disease limited to segment II and III of the liver.

Caroli's disease is defined as a abnormal dilatation of the intra-hepatica bile ducts: Its  incidence is extremely low  (1 in 1,000,000 population) and in ...

Biology

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.

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 ...

Cancer Research

Laparoscopic Anterior Right Hepatectomy: A Single-Center Experience

Laparoscopic anterior right hepatectomy (LARH) has been used in some hospitals. However, data on the feasibility and safety of this procedure are still limited, due to the demanding technical requirements. The primary objective of this study was to compare the clinical outcomes of LARH with those of laparoscopic conventional right hepatectomy (LCRH) in patients with large right hepatocellular carcinoma, as well as to confirm the safety and feasibility of LARH. Furthermore, the article presents a step-by-step description of the surgical procedures for LARH to help perform this surgery in the clinic. The principle of LARH is to first prioritize the hepatic inlet duct separation while separating the right hepatic perihepatic ligament after transecting the liver. From December 2015 to June 2022, 82 patients with large right hepatocellular carcinoma (maximum tumor diameter &#8805; 5 cm), were recruited for the study. In this cohort, 54 and 28 patients underwent LARH and LCRH, respectively. The perioperative clinical data and survival outcomes of the two groups were compared. Compared with LCRH, LARH exhibited the advantages of less contact and extrusion, thereby leading to the achievement of superior results. Thus, we propose that LARH is the optimal choice for patients with large right hepatocellular carcinoma.

Here we present a step-by-step protocol for conducting laparoscopic anterior right hepatectomy and compare its clinical effects and postoperative outcomes with those of conventional hepatectomies. Analysis of the data of 82 patients with hepatocellular carcinoma revealed that laparoscopic anterior right hepatectomy had better clinical outcomes and survival rates than the conventional hepatectomy.

Laparoscopic anterior right hepatectomy (LARH) has been used in some hospitals. However, data on the feasibility and safety of this procedure are still ...

Behavior

Robotic Left Hepatectomy using Indocyanine Green Fluorescence Imaging for an Intrahepatic Complex Biliary Cyst

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. Surgery is the cornerstone treatment for patients with BC. While total BC excision and Roux-Y hepaticojejunostomy is the treatment method of the choice in patients with extrahepatic BC (i.e., Todani I-IV), patients with intrahepatic BC (i.e., Todani V) benefit the most from a surgical liver resection. In recent years, minimally invasive liver surgery (MILS) including robotic MILS has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. Robotic major MILS is still considered technically demanding and a detailed description of the technical approach during robotic major MILS has only been limitedly discussed in the literature. The current article describes the main steps for a robotic left hepatectomy in a patient with a large BC Todani Type V. The patient is in French position with 5 trocars placed (4 robotic, 1 laparoscopic assistant). After mobilizing the left hemiliver, the left and right hepatic artery are dissected carefully followed by a cholecystectomy. Intraoperative ultrasound is performed to confirm localization and margins of the BC. The Left hepatic artery and left portal vein are isolated, clipped, and divided. Indocyanine green (ICG) fluorescence imaging is used regularly during the entire procedure to visualize and confirm biliary tract anatomy and the BC. Parenchymal transection is performed with robotic cautery hook for the superficial part and robotic cautery spatula, bipolar cautery, and vessel sealer for the deeper parenchyma. The postoperative course was uncomplicated. A robotic left hepatectomy is technically demanding, yet a feasible and safe procedure. ICG-fluorescence imaging aids in delineating the BC and bile duct anatomy. Further, comparative studies are needed to confirm clinical benefits of robotic MILS for benign and malignant indications.

Robotic liver surgery has gained more acceptance as a feasible, safe, and effective procedure for the treatment of both benign and malignant indications. However, robotic left hepatectomy is still technically demanding. We describe our surgical technique of a robotic left hepatectomy using indocyanine green fluorescence imaging for a large biliary cyst.

Biliary cysts (BC) are rare congenital dilatations of intra- and extrahepatic parts of the biliary tract and bear a significant risk of carcinogenesis. ...

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In this study, a 32-year-old male patient with Bismuth Type IVa hilar cholangiocarcinoma underwent radical robotic resection of hepatic S4b, S5, and S1 (Taj Mahal hepatectomy) combined with regional lymphadenectomy, hilar bile duct reconstruction, and hepaticojejunostomy by the robotic surgical system. Postoperative pathological examination showed moderately-differentiated adenocarcinoma of the hilar bile duct. The surgical margins of the liver and bile ducts were negative. Recovery was smooth and the patient was discharged on the 17th postoperative day. The robotic surgical system and associated multiple instruments along with flexible and precise movements is suitable for the local hepatectomy around the porta hepatis, and delicate reconstruction of the hilar bile duct with a smaller diameter. This first clinical application study found that robotic Taj Mahal hepatectomy for hilar cholangiocarcinoma is safe and feasible and needs more experience for the evaluation of its long-term outcomes.

Robotic resection of hepatic S4b, S5, and S1 using the Taj Mahal procedure is feasible and safe for selected patients with hilar cholangiocarcinoma. The step-by-step details for this surgery are presented here.

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...

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 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 Choledochal Cyst Excision and Roux-en-Y Choledochojejunostomy in Adults

Choledochal cysts (CCs), known as congenital choledochal dilatations, are more prevalent in Asia. The majority of patients with abdominal symptoms are diagnosed and treated during early childhood, which results in a lower prevalence of CCs in adults. The treatment of choice for CCs is complete cyst excision followed by choledochojejunostomy. Laparoscopic surgery is now more widely accepted than traditional open surgery due to its smaller incisions, faster recovery, and less postoperative pain. However, there are few reports on laparoscopic excision of CCs in adults. This article presents a protocol that describes and demonstrates the complete procedure for laparoscopic excision of a choledochal cyst and Roux-en-Y choledochojejunostomy. A 32-year-old woman diagnosed with a 2.5 cm by 3 cm CC underwent surgery using a laparoscopic approach with post-colonic anastomosis. The procedure lasted 290 min with an estimated blood loss of approximately 100 mL. A follow-up abdominal CT scan on the sixth postoperative day showed a satisfactory recovery, leading to her discharge on the ninth day. This study aims to demonstrate the feasibility and safety of laparoscopically assisted excision of CCs in adults. This procedure is expected to become the preferred surgical option for CCs in adults due to its minimal surgical trauma and rapid postoperative recovery.

Choledochal cysts in adults are relatively rare, and few reports have detailed treatment options. Here, we present a case demonstrating laparoscopic resection of choledochal cysts and posterior colonic Roux-en-Y choledochojejunostomy in adults, offering an alternative for clinical management.

Choledochal cysts (CCs), known as congenital choledochal dilatations, are more prevalent in Asia. The majority of patients with abdominal symptoms are ...

Complete Laparoscopic Radical Resection of Perihilar Cholangiocarcinoma Type IIIb

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