The study is self-sponsored.

The protocol follows the guidelines of Kwong Wah Hospital&#39;s human research ethics committee.
1. Pre-operative workup
<ol>
	<li>Check triphasic CT scans to evaluate the extent of disease and vascular anatomy.</li>
	<li>Perform an indocyanine green (ICG) retention test to assess liver function properly. Preferably, ICG retention of less than 15% is required for patients to undergo major liver resection13.</li>
	<li>Perform CT volumetry to ensure adequate residual liver volume (RLV). 40% RLV is required for cirrhotic liver, while 30% RLV is necessary for the normal liver14.</li>
</ol>
2. Anesthesia
<ol>
	<li>Administer pre-operative antibiotics, typically 1.2 g of amoxicillin and clavulanic acid, intravenously on induction of anesthesia.</li>
	<li>Perform deep venous thrombosis prophylaxis with a sequential compression device and compression stockings15.</li>
	<li>Place an arterial line and a central venous line.</li>
	<li>Control low central venous pressure to 3-8 mmHg16. An anesthetist performs this.</li>
</ol>
3. Patient positioning
<ol>
	<li>Position the patient in the Lloyd-Davis position on a split-leg table.</li>
	<li>Set the theatre as depicted in Figure 2, allowing the surgeon to stand between the patient&#39;s legs. 
	NOTE: This position allows the surgeon to operate while standing between the legs, providing ergonomic benefits during such a lengthy procedure and preventing early fatigue.</li>
	<li>Elevate the patient to 30&#176; left lateral position with a pillow during the operation.</li>
</ol>
4. Port site insertion and the laparoscope
<ol>
	<li>Establish access into the intraabdominal cavity with a sub-umbilical incision by open Hasson Technique17.</li>
	<li>Place the remaining ports as depicted in Figure 3.</li>
	<li>Place a 12 mm port in the right upper quadrant along the midclavicular line.</li>
	<li>Place 5 mm laparoscopic assistant port at epigastrium, right flank along the anterior axillary line, and left upper quadrant. 
	NOTE: A laparoscope with a flexible tip is preferred for a better view above the dome of the liver (Figure 4).</li>
</ol>
5. Operative steps
<ol>
	<li>Mobilization of the whole right lobe of the liver
	<ol>
		<li>Expose the root of the right hepatic vein superiorly.
		<ol>
			<li>Complete division of triangular ligament until bare area exposed.</li>
			<li>Expose the groove between the right hepatic veins and the common trunk of the middle and left hepatic veins.</li>
		</ol>
		</li>
		<li>Expose the root of IVC inferiorly.
		<ol>
			<li>Incise inferior peritoneal attachment and drop the adrenal gland to the retroperitoneum.</li>
			<li>Divide the short hepatic veins and vena cava ligament until the inferior border of the right hepatic vein is seen.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Right posterior pedicle control with intrahepatic Glissonian approach18.
	<ol>
		<li>Dissect along the superior border of the right posterior Glissonian pedicle along the Rouviere sulcus while keeping the Laennec capsule intact.</li>
		<li>Transect the caudate process to expose the inferior margin of the right posterior Glissonian pedicle.</li>
		<li>Dissect along the inferior border of the right posterior Glissonian pedicle along the Rouviere sulcus while keeping the Laennec capsule intact.</li>
		<li>Control the right posterior pedicle temporarily with a bulldog clamp.</li>
	</ol>
	</li>
	<li>Determination of the transection plane along the ischaemic line
	<ol>
		<li>Perform Intraoperative ultrasonography (USG) to identify the course of the right hepatic vein19.</li>
		<li>Open the liver capsule with an ultrasonic scalpel (Table of Materials) at the dome of the liver along the left margin of the right hepatic vein to secure a correct transection plane.</li>
		<li>Mark the rest of the transection line along the ischaemic line with diathermy.</li>
	</ol>
	</li>
	<li>Pringle maneuver
	<ol>
		<li>Prepare intracorporeal tourniquet for laparoscopic Pringle maneuver by Huang&#39;s Loop using a shortened Foley catheter20.</li>
	</ol>
	</li>
	<li>Parenchymal transection
	<ol>
		<li>Open the liver capsule with an ultrasonic scalpel along the planned transection line.</li>
		<li>Perform subsequent deep parenchymal transection with the &#39;ultrasonic scalpel mimic CUSA&#39; technique12.
		<ol>
			<li>Keep both arms of the ultrasonic scalpel open.</li>
			<li>Use the active blade of the ultrasonic scalpel to dissect the tissue.</li>
			<li>Activate maximum and move the active blade in a horizontal swinging motion parallel to the vasculobiliary structure.</li>
			<li>Dissect the parenchyma while exposing the individual intrahepatic vessels and leaving them intact.</li>
			<li>Use a suction device with the left hand constantly to keep the surgical field dry.</li>
			<li>Divide small vessels with the ultrasonic scalpel.</li>
			<li>Divide large vessels or pedicle structures between plastic clips (Table of Materials) or metal clips.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Right posterior pedicle transection
	<ol>
		<li>Encircle the right posterior pedicle with vascular tape.</li>
		<li>Transect the right posterior pedicle with a vascular stapler.</li>
	</ol>
	</li>
	<li>Right hepatic vein transection
	<ol>
		<li>Transect the right hepatic vein with a vascular stapler.</li>
	</ol>
	</li>
	<li>Bleeding control
	<ol>
		<li>The right posterior pedicle is temporarily controlled as a form of partial Pringle&#39;s maneuver during parenchymal transection. Meticulous dissection and identification of intrahepatic vessels are critical. Divide portal and hepatic venules with clips or ultrasonic scalpel.</li>
		<li>Use bipolar diathermy for bleeding with simultaneous suctioning to clear the surgical field.</li>
		<li>Increase carbon dioxide pneumoperitoneum (15-20 mmHg) to slow down the bleeding from hepatic veins and use intracorporal suture for significant bleeding, for example, bleeding from the right hepatic vein.</li>
		<li>Use a suture to secure bleeding from large veins or arteries.</li>
	</ol>
	</li>
</ol>
6. Specimen retrieval
<ol>
	<li>The specimen is put into a plastic bag and retrieved through the Pfannenstiel incision.</li>
</ol>

Advancing LRPS: Optimal Techniques for Challenging Liver Resections

<ol>
	<li>van der Heijde, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+right+posterior+sectionectomy:+an+international,+multicenter,+propensity+score-matched+evaluation.">Laparoscopic versus open right posterior sectionectomy: an international, multicenter, propensity score-matched evaluation.</a> Surgical Endoscopy. 35 (11), 6139-6149 (2021).</li><li>Cheng, K. C., Yeung, Y. P., Ho, K. M., Chan, F. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+right+posterior+sectionectomy+for+malignant+lesions:+An+anatomic+approach.">Laparoscopic right posterior sectionectomy for malignant lesions: An anatomic approach.</a> Journal of Laparoendoscopic &amp; Advanced Surgical Techniques. Part A. 25 (8), 646-650 (2015).</li><li>Fretland, A. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+resection+for+colorectal+liver+metastases:+The+OSLO-COMET+randomized+controlled+trial.">Laparoscopic versus open resection for colorectal liver metastases: The OSLO-COMET randomized controlled trial.</a> Annals of Surgery. 267 (2), 199-207 (2018).</li><li>Landi, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Short-term+outcomes+of+laparoscopic+vs.+open+liver+resection+for+hepatocellular+adenoma:+a+multicenter+propensity+score+adjustment+analysis+by+the+AFC-HCA-2013+study+group.">Short-term outcomes of laparoscopic vs. open liver resection for hepatocellular adenoma: a multicenter propensity score adjustment analysis by the AFC-HCA-2013 study group.</a> Surgical Endoscopy. 31 (10), 4136-4144 (2017).</li><li>Cho, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safe+and+feasible+extrahepatic+Glissonean+access+in+laparoscopic+anatomical+liver+resection.">Safe and feasible extrahepatic Glissonean access in laparoscopic anatomical liver resection.</a> Surgical Endoscopy. 25 (4), 1333-1336 (2011).</li><li>Oztas, M., Lapsekili, E., Fatih Can, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+liver+right+posterior+sectionectomies;+surgical+technique+and+clinical+results+of+a+single+surgeon+experience.">Laparoscopic liver right posterior sectionectomies; surgical technique and clinical results of a single surgeon experience.</a> Turkish Journal of Surgery. 38 (1), 18-24 (2022).</li><li>Siddiqi, N. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+right+posterior+sectionectomy+(LRPS):+surgical+techniques+and+clinical+outcomes.">Laparoscopic right posterior sectionectomy (LRPS): surgical techniques and clinical outcomes.</a> Surgical Endoscopy. 32 (5), 2525-2532 (2018).</li><li>Machado, M. A., Makdissi, F. F., Galvao, F. H., Machado, M. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intrahepatic+Glissonian+approach+for+laparoscopic+right+segmental+liver+resections.">Intrahepatic Glissonian approach for laparoscopic right segmental liver resections.</a> The American Journal of Surgery. 196 (4), e38-e42 (2008).</li><li>Machado, M. A., Kalil, A. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Glissonian+approach+for+laparoscopic+mesohepatectomy.">Glissonian approach for laparoscopic mesohepatectomy.</a> Surgical Endoscopy. 25 (6), 2020-2022 (2011).</li><li>Topal, B., Aerts, R., Penninckx, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+intrahepatic+Glissonian+approach+for+right+hepatectomy+is+safe,+simple,+and+reproducible.">Laparoscopic intrahepatic Glissonian approach for right hepatectomy is safe, simple, and reproducible.</a> Surgical Endoscopy. 21 (11), 2111 (2007).</li><li>Park, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+and+Risk+factors+of+pure+laparoscopic+living+donor+right+hepatectomy:+Comparison+to+open+technique+in+propensity+score-matched+analysis.">Safety and Risk factors of pure laparoscopic living donor right hepatectomy: Comparison to open technique in propensity score-matched analysis.</a> Transplantation. 103 (10), e308-e316 (2019).</li><li>Yang, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+liver+resection+with+&amp;#34;ultrasonic+scalpel+mimic+CUSA&amp;#34;+technique.">Laparoscopic liver resection with &amp;#34;ultrasonic scalpel mimic CUSA&amp;#34; technique.</a> Surgical Endoscopy. 36 (12), 8927-8934 (2022).</li><li>Kitano, S., Kim, Y. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ICG+clearance+in+assessing+cirrhotic+patients+with+hepatocellular+carcinoma+for+major+hepatic+resection.">ICG clearance in assessing cirrhotic patients with hepatocellular carcinoma for major hepatic resection.</a> HPB Surgery. 10 (3), 182-183 (1997).</li><li>Lim, M. C., Tan, C. H., Cai, J., Zheng, J., Kow, A. W. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=CT+volumetry+of+the+liver:+Where+does+it+stand+in+clinical+practice.">CT volumetry of the liver: Where does it stand in clinical practice.</a> Clinical Radiology. 69 (9), 887-895 (2014).</li><li>Sachdeva, A., Dalton, M., Lees, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Graduated+compression+stockings+for+prevention+of+deep+vein+thrombosis.">Graduated compression stockings for prevention of deep vein thrombosis.</a> Cochrane Database of Systematic Reviews. 11 (11), CD001484 (2018).</li><li>Liu, T. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Application+of+controlled+low+central+venous+pressure+during+hepatectomy:+A+systematic+review+and+meta-analysis.">Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis.</a> Journal of Clinical Anesthesia. 75, 110467 (2021).</li><li>Ellison, E. C., Zollinger, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Zollinger's Atlas of Surgical Operations. , (2016).</li><li>Kato, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Minimally+invasive+anatomic+liver+resection+for+hepatocellular+carcinoma+using+the+extrahepatic+Glissonian+approach:+Surgical+techniques+and+comparison+of+outcomes+with+the+open+approach+and+between+the+laparoscopic+and+robotic+approaches.">Minimally invasive anatomic liver resection for hepatocellular carcinoma using the extrahepatic Glissonian approach: Surgical techniques and comparison of outcomes with the open approach and between the laparoscopic and robotic approaches.</a> Cancers (Basel). 15 (8), 2219 (2023).</li><li>Kamiyama, T., Kakisaka, T., Orimo, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+role+of+intraoperative+ultrasonography+in+hepatectomy.">Current role of intraoperative ultrasonography in hepatectomy.</a> Surgery Today. 51 (12), 1887-1896 (2021).</li><li>Huang, J. W., Su, W. L., Wang, S. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Alternative+laparoscopic+intracorporeal+Pringle+maneuver+by+Huang's+loop.">Alternative laparoscopic intracorporeal Pringle maneuver by Huang's loop.</a> World Journal of Surgery. 42 (10), 3312-3315 (2018).</li><li>. Laparoscopes articulating HD 3D videoscope ENDOEYE FLEX 3D (LTF-190-10-3D) Available from: <a target="_blank" href="https://medical.olympusamerica.com/products/laparoscopes/endoeye-flex-3d">https://medical.olympusamerica.com/products/laparoscopes/endoeye-flex-3d</a> (2023)</li><li>Welling, A., Scoggins, P., Cummings, J., Clymer, J., Amaral, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Superior+dissecting+capability+of+a+new+ultrasonic+device+improves+efficiency+and+reduces+adhesion+formation.">Superior dissecting capability of a new ultrasonic device improves efficiency and reduces adhesion formation.</a> Global Surgery. 3 (1), (2017).</li><li>Lortat-Jacob, J. L., Robert, H. G., Henry, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Case+of+right+segmental+hepatectomy.">Case of right segmental hepatectomy.</a> Memoires. Academie de Chirurgie (Paris). 78 (8-9), 244-251 (1952).</li><li>Takasaki, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Glissonean+pedicle+transection+method+for+hepatic+resection:+a+new+concept+of+liver+segmentation.">Glissonean pedicle transection method for hepatic resection: a new concept of liver segmentation.</a> Journal of Hepato-Biliary-Pancreatic Surgery. 5 (3), 286-291 (1998).</li><li>Ramacciato, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effective+vascular+endostapler+techniques+in+hepatic+resection.">Effective vascular endostapler techniques in hepatic resection.</a> International Surgery. 83 (4), 317-323 (1998).</li><li>Figueras, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hilar+dissection+versus+the+&amp;#34;glissonean&amp;#34;+approach+and+stapling+of+the+pedicle+for+major+hepatectomies:+a+prospective,+randomized+trial.">Hilar dissection versus the &amp;#34;glissonean&amp;#34; approach and stapling of the pedicle for major hepatectomies: a prospective, randomized trial.</a> Annals of Surgery. 238 (1), 111-119 (2003).</li><li>Jegadeesan, M., Jegadeesan, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anatomical+basis+of+approaches+to+liver+resection.">Anatomical basis of approaches to liver resection.</a> Acta Scientific Gastrointestinal Disorders. 3 (12), 17-23 (2020).</li><li>Eikermann, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevention+and+treatment+of+bile+duct+injuries+during+laparoscopic+cholecystectomy:+the+clinical+practice+guidelines+of+the+European+Association+for+Endoscopic+Surgery+(EAES).">Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES).</a> Surgical Endoscopy. 26 (11), 3003-3039 (2012).</li><li>Imamura, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prognostic+significance+of+anatomical+resection+and+des-gamma-carboxy+prothrombin+in+patients+with+hepatocellular+carcinoma.">Prognostic significance of anatomical resection and des-gamma-carboxy prothrombin in patients with hepatocellular carcinoma.</a> British Journal of Surgery. 86 (8), 1032-1038 (1999).</li><li>Lee, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Application+of+temporary+inflow+control+of+the+Glissonean+pedicle+method+provides+a+safe+and+easy+technique+for+totally+laparoscopic+hemihepatectomy+by+Glissonean+approach.">Application of temporary inflow control of the Glissonean pedicle method provides a safe and easy technique for totally laparoscopic hemihepatectomy by Glissonean approach.</a> Annals of Surgical Treatment and Research. 92 (5), 383-386 (2017).</li><li>Otsuka, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=What+is+the+best+technique+in+parenchymal+transection+in+laparoscopic+liver+resection?+Comprehensive+review+for+the+clinical+question+on+the+2nd+International+Consensus+Conference+on+Laparoscopic+Liver+Resection.">What is the best technique in parenchymal transection in laparoscopic liver resection? Comprehensive review for the clinical question on the 2nd International Consensus Conference on Laparoscopic Liver Resection.</a> Journal of Hepato-Biliary-Pancreatic Sciences. 22 (5), 363-370 (2015).</li><li>Jia, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+liver+resection:+a+review+of+current+indications+and+surgical+techniques.">Laparoscopic liver resection: a review of current indications and surgical techniques.</a> Hepatobiliary Surgery and Nutrition. 7 (4), 277-288 (2018).</li></ol>

The authors have nothing to disclose.

The critical components of the surgery include the intrahepatic Glissonian approach for inflow control, a &#39;ultrasonic scalpel mimic CUSA&#39; parenchymal transection technique, early identification of right hepatic vein and meticulous bleeding control by bipolar diathermy.
The first critical step in this protocol is identifying and controlling the right posterior pedicle. The Glissonian approach was first introduced as extrahepatic Glissonian pedicle control in open liver surgery<sup class...

Laparoscopic liver surgery has been shown to have several advantages over open liver resection, including reduced blood loss, decreased wound pain, and shorter hospital stay while maintaining comparable oncological outcomes1,2,3,4. Although LRPS was previously considered a relative contraindication due to its deep-seated anatomic location and challenges in bleeding control, recent advancements have proven its safety and feasibility2,5,6,7. Various strategies and surgical devices have been developed to overcome these challenges. However, no consensus exists on the best surgical technique and devices for LRPS.
In this article, we aim to provide a detailed description of the steps involved in LRPS at our centre, with a specific focus on the intrahepatic Glissonian approach for inflow control, a novel technique called the &#39;ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)&#39; for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy. Machado et al. and Topal et al. reported the feasibility and safety of the laparoscopic intrahepatic Glissonian approach8,9,10. Laparoscopic techniques offer improved visualization and precision in dissecting the Glissonian pedicle. The approach maintains the blood flow to the remnant liver, reducing the risk of ischaemic injury. Additionally, this approach allows for the exact demarcation of liver segments that are being resected, making the surgery more precise and reducing the risk of bleeding. Professor Kwon introduced the &#39;ultrasonic scalpel mimic CUSA&#39; technique in 201911, which has been shown to reduce intraoperative blood loss and operative time11,12.
A representative case is discussed in this study to detail the steps performed in the protocol. The patient is a 54-year-old man who is a chronic carrier of hepatitis B. During screening ultrasonography, a liver mass was identified in segment 6. A pre-operative triphasic computed tomography (CT) scan was performed, which revealed a 5.7 cm hypervascular tumor with arterial enhancement and portovenous washout in segment 7 (Figure 1).&#160;The alpha-fetoprotein (AFP) level was 2 ng/ml. The Child-Pugh score was 5 (Grade A). The indocyanine green retention at 15 min was 7.5%. The residual liver volume (RLV) was 45%. Based on the patient&#39;s hepatitis status and the radiological features of the tumor, the mass was treated as hepatocellular carcinoma. The patient was offered a laparoscopic right posterior sectionectomy, including the right hepatic vein.

<table><tbody><tr><td>3D ENDOEYE Flex</td><td>Olympus&amp;nbsp;</td><td>LTF-S190-10-3D</td><td>Flexible tip laparoscopic camera</td></tr><tr><td>5 mm ROBI Bipolar Grasping Forceps</td><td>KARL STORZ</td><td>38851 ON</td><td>atraumatic, fenestrated forceps</td></tr><tr><td>AESCULAP Challenger Ti-P</td><td>Barun</td><td>PL520L</td><td>Pneumatic driven multi-fire clip applicator. 5 mm metal clips</td></tr><tr><td>Endo GIA Reloads with Tri-Staple Technology, 30 mm, Tan colour</td><td>Medtronic&amp;nbsp;</td><td>SIG30AVM</td><td>Tristaple system that has stepped cartridge face that delivers graduated compression and three rows of varied height staples. Staple height 2 mm, 2.5 mm, 3 mm.</td></tr><tr><td>Endo GIA Ultra Universal Stapler</td><td>Medtronic&amp;nbsp;</td><td>EGIAUSTND</td><td>Manual stapler that compresses tissue while it simultaneously lays down a staple line and transects the tissue</td></tr><tr><td>HARMONIC ACE+7 Shears</td><td>Ethicon</td><td>HARH36</td><td>Curved tip, energy sealing and dissecting, diameter 5 mm, length 36 cm</td></tr><tr><td>Hem-o-lok Clips L</td><td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td><td>544240</td><td>Vascular clip 5&amp;ndash;13 mm Size Range</td></tr><tr><td>Hem-o-lok Clips ML</td><td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td><td>544230</td><td>Vascular clip 3&amp;ndash;10 mm Size Range</td></tr><tr><td>Hem-o-Lok Polymer Ligation System</td><td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td><td>544965</td><td></td></tr><tr><td>Profocus 2202 Ultraview 800</td><td>BK Medical&amp;nbsp;</td><td>N/A</td><td>Intraoperative Ultrasonography</td></tr></tbody></table>

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.

In the representative case, the total operative time was 738 min, with an estimated blood loss of 400 mL. The patient was nursed in the intensive care unit for 2 days. The recovery was uneventful, and the patient was discharged on postoperative day 5. Histopathological examination of the specimen revealed moderately differentiated cholangiocarcinoma measured 8.0 cm x 5.5 cm x 4.5 cm. There was no perineural or lymphovascular permeation. The resection margin was 14 mm. The American Joint Committee on Cancer (AJCC) staging...

Watch this Scientific Journal Video about Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique at JoVE.com

Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

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 ...

techniques-laparoscopic-right-posterior-sectionectomy-glissonian

Research

JoVE Journal

Medicine

745 Views.  Kwong Wah Hospital. 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.

Video: Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis.
The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index &#62;35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers.
The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy.
The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.

Laparoscopic pancreatoduodenctomy (LPD) may offer advantages over open pancreatoduodenectomy, including early postoperative mobilization, less delayed gastric emptying and a shorter hospital stay. However, LPD is technically challenging and not well-standardized, especially regarding the pancreatic anastomosis. We describe a standardized technique for the pancreatic anastomosis during LPD: modified Blumgart pancreaticojejunostomy.

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal ...

Cancer Research

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 ...

Right Hemihepatectomy by Suprahilar Intrahepatic Transection of the Right Hemipedicle using a Vascular Stapler

Successful hepatic resection requires profound anatomical knowledge and delicate surgical technique. Hemihepatectomies are mostly performed after preparing the extrahepatic hilar structures within the hepatoduodenal ligament, even in benign tumours or liver metastasis.1-5. Regional extrahepatic lymphadenectomy is an oncological standard in hilar cholangiocarcinoma, intrahepatic cholangio-cellular carcinoma and hepatocellular carcinoma, whereas lymph node metastases in the hepatic hilus in patients with liver metastasis are rarely occult. Major disadvantages of these procedures are the complex preparation of the hilus with the risk of injuring contralateral structures and the possibility of bleeding from portal vein side-branches or impaired perfusion of bile ducts. We developed a technique of right hemihepatectomy or resection of the left lateral segments with intrahepatic transection of the pedicle that leaves the hepatoduodenal ligament completely untouched. 6 However, if intraoperative visualization or palpation of the ligament is suspicious for tumor infiltration or lymph node metastasis, the hilus should be explored and a lymphadenectomy performed.

This video describes a right hemihepatectomy with intrahepatic transection of the right hemipedicle leaving the hepatoduodenal ligament completely untouched.

Successful hepatic resection requires profound anatomical knowledge and delicate surgical technique. Hemihepatectomies are mostly performed after ...

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

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

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 ...

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 ...

Peripheral Subtractive Dissection of Glissonean Pedicles in Minimally Invasive Anatomic Liver Resection for Right Posterior Lobe Tumors

Minimally invasive anatomic liver resection (MIALR) has recently garnered significant attention and has rapidly advanced in the field of hepatobiliary surgery. In particular, the dissection of the Glissonean pedicle, such as in Atsushi Sugioka's Gate Theory, represents a fundamental operative technique within MIALR. This technique is based on the anatomical structure of the Laennec capsule, thereby promoting and implementing MIALR in a scientifically rigorous manner. However, potential risks such as hemorrhage, ischemia-reperfusion injury (IRI), and tumor rupture may arise during MIALR in clinical practice, particularly when it is applied to tumors located in the right posterior hepatic lobe near the bifurcation of the Glissonean pedicles (excluding hilar cholangiocarcinoma). To address these challenges, this study introduces a unique surgical approach, termed peripheral subtractive dissection of the Glissonean pedicle (PSDGP), designed to mitigate these potential complications. During the PSDGP procedure in MIALR for liver tumors, the cystic plate approach is utilized to facilitate extrahepatic dissection. Initially, a non-absorbable suture is threaded from Gate VI to Gate IV under the guidance of non-traumatic forceps (or similar instruments). Subsequently, the non-traumatic forceps are passed through Gate V again to retrieve the non-absorbable suture from Gate IV. Finally, both Gate V and Gate VI are used to achieve the separation of the right posterior Glissonean pedicle. This method may improve surgical success rates and yield better oncological outcomes due to its strict adherence to the no-touch and en-bloc principles of tumor resection.

Minimally invasive anatomic liver resection (MIALR) involving Glissonean pedicle ligation for the right posterior hepatic lobe may cause tumor rupture, hemorrhage, and ischemia-reperfusion injury (IRI). This study proposes a novel surgical approach, peripheral subtractive dissection of the Glissonean pedicle (PSDGP), aimed at mitigating these risks.

Minimally invasive anatomic liver resection (MIALR) has recently garnered significant attention and has rapidly advanced in the field of hepatobiliary ...