Surgery is considered the most effective method to improve the prognosis in patients with hepatocellular carcinoma. However, the right hepatectomy is a difficult procedure. The development of laparoscopic surgery and the use of the anterior approach in right hepatectomy have promoted the laparoscopic anterior right hepatectomy, LARH.
In LARH, the hepatic inlet duct is dissected first, and the right hepatic perihepatic ligament is freed after liver transection. The hanging maneuver used in LARH can help increase the resection rate of large right liver tumor. We conducted this study to evaluate the feasibility and safety of LARH, and our findings confirmed the strength of LARH.
This study was approved from the Zhujiang Hospital of Southern Medical University Committee on August 25th, 2021. Here we report the case of a 44-year-old woman whose enhanced computerized tomography scan of the upper abdomen showed a 9.5 by 9.0 by 7.0 cubic centimeters hypointense mass occupying the right liver. Physical examination and laboratory tests revealed no significant abnormalities.
The admission diagnosis revealed primary right liver tumor and we performed LARH. Prohibit patient from eating and drinking before surgery. Use tracheal intubation under general anesthesia.
Sterilize the skin with 0.5%iodine based scrub and treat patient with conventional sterilized skin and sterile towel sheets. Place the patient in a supine position with the head of the bed elevated, the feet of the bed lowered, and the right side of the patient's body tilted at 15 degrees. Make five different curved incisions.
Use the pneumoperitoneum needle to penetrate the abdominal cavity through the incision and set the pneumoperitoneum pressure to 13 millimeters of mercury. Consider the curved incision on the umbilicus as the laparoscopic hole, A, two one centimeter curved incisions, B and E, as the main operating holes, and two five millimeters curved incisions, C and D, as the auxiliary operating holes. The trocar of five, ten, ten, five, and five millimeters were punctured the umbilicus, A, below the xiphoid process, B, the midclavicular line, E, anterior axillary line under the right costal margin, C, and between operation incisions A and B, D.Perform abdominal exploration by penetrating the abdominal cavity.
Dissect the recess between the root of the middle hepatic vein, MHV, and the right hepatic vein, RHV. Separate the gallbladder triangle with an ultrasonic knife to expose the gallbladder duct and artery. Cut off them and remove the gallbladder.
Ensure the assistant assists in lifting the liver and the operator separates the right hepatic artery and right branch of the portal vein with an ultrasonic knife and aspirator. Then use a suture to ligate the RPV but do not transect it first, and use a homo lock to clamp the RHA. Trace the IVC bottom-up and, for the short hepatic veins, wound and ligate them and then clamp them using an ultrasonic knife to access the avascular area behind the liver.
Insert the Goldfinger dissector through the hepatic posterior space and exit through the hepatic vein recess. Fix an urinary catheter at the Goldfinger dissector and bypass the liver to establish a retro hepatic tunnel. Use the urinary catheter to lift the liver and assist in exposing the liver resection plane during liver dissection.
Transect the liver parenchyma with an ultrasonic knife along the hepatic ischemic line and no significant bleeding occurred until the tumor was removed along with the right liver. Firstly, open the inferior hepatoduodenal ligament with an ultrasonic knife and use the sterile bracelet to bypass the hepatoduodenal ligament as a pre-blocking band to perform the first hilar occlusion and reduce bleeding if necessary. When possible, use an ultrasonic knife to transect the liver parenchyma along the MHV and during the process, thicker pipes that are encountered can be cut off by suture ligation and homo lock clipping.
Separately free the right anterior and posterior glistens and subsequently transect them using Endo-GIA. Transect the RHV using Endo-GIA. After completely cut off the liver parenchyma, examine the presence of reflux vessels from the bottom-up and separate and ligate the vessels one by one.
Separate the right hepatic coronary and triangular ligaments using an ultrasonic knife with the help of the assistant to ensure exposure. Place the specimen in a specimen bag and make a transverse incision at the intersection of the right midclavicular line and the umbilical line, line red, to remove the specimen altogether. Place a laparoscopic drainage tube at the liver section and exit from the right lower abdomen after confirming no active bleeding in the abdominal cavity.
The postoperative enhanced CT showed changes after the right hepatocellular carcinoma was resected, suggesting a different resected right liver with indentation of external drainage tube in the operative area compared with that observed during preoperative imaging. The relevant outcomes of LARH are shown in table one. The patient featured in the video recovered well after the surgery and was sent back to the ward.
The operation lasted 180 minutes with an intraoperative blood loss of approximately 150 milliliters that did not require blood transfusion. Intraoperative urinary output was 800 milliliters. The time of establishing the retro hepatic tunnel and transecting the liver parenchyma are 15 minutes and 35 minutes, respectively, and the times of Pringle is two.
The patient recovered well without postoperative complications and was discharged on the eighth postoperative day. The patient's disease-free survival period was 17 months and was still alive. The figure one and eight showed the difference between preoperative and postoperative CT of the patient.
The intraoperative blood loss among the patients in the LARH group was less than that of the patients in the laparoscopic conventional right hepatectomy, LCRH group. The retro hepatic tunnel was successfully established in patients who underwent LARH without massive hemorrhage and the catheter was used to complete the hanging maneuver. The median time for establishing the retro hepatic tunnel in patients in the LARH group was 15 minutes.
The liver parenchyma transection time among patients in the LARH group was less. Moreover, the patients in the LARH group had shorter postoperative hospital stays. The complication rates in the LARH group was better than that in the LCRH group.
The two groups of patients successfully completed the operation and no death occurred after the operation. Four of the 82 patients were lost to follow up, and 78 patients were included in a survival analysis at a follow up of eight to 69 months with a median follow up of 32 months. In the LARH group, the one, three, and five year DFS rates were better than those in the LCRH Group from the figure 10.
The one, three, and five-year OS rates were better in the LARH group compared to those in the LCRH group from the figure 11. Multivariate analysis indicated that LARH, and no vascular tumor thrombus, and blood loss less than 250 milliliters were associated with longer DFS from the table four. Conclusion:Based on our results, we concluded that LARH can effectively reduce blood loss, accelerate liver transection, and reduce tumor recurrence compared with LCRH.
LARH involves less contact and extrusion, which agrees with the tumor-free principle"Therefore, we propose that LARH could be a useful treatment strategy for large right hepatocellular carcinoma.
