Laparoscopic Left Approach Resection of the Caudate Lobe

Summary

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.

Abstract

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.

Introduction

The caudate lobe is situated deep within the liver, with its specific coverage extending from the front of the inferior vena cava, reaching behind the left, middle, and right hepatic veins, upward to where the three main hepatic veins converge into the inferior vena cava, and downward to the hepatic hilum¹.

Since the pioneering report by Dulucq et al. in 2006 on laparoscopic resections of the hepatic caudate lobe, numerous cases involving isolated resections of the caudate lobe and segmental resections have been documented^2,3,4,5,6,7. However, the technical complexity of laparoscopic caudate lobectomy is subject to a multitude of factors. These include stringent adherence to surgical indications, comprehensive preoperative assessment of imaging data, mastery of laparoscopic surgical techniques, intimate knowledge of the local anatomy of the caudate lobe, and the judicious selection of surgical approaches. At present, there are four prevalent approaches for the resection of the caudate lobe: the left-sided approach, the right-sided approach, the combined left-right approach, and the anterior approach. The left-sided approach is typically employed for the resection of the Spiegel lobe or when a combined resection of the left lateral segment or left hemi liver is required. Conversely, the right-sided approach is favored for the resection of the caudate process or, in cases necessitating a right hemi liver resection. In instances where the tumor is disproportionately large or extensively infiltrates the caudate lobe, thereby complicating exposure via the left or right approach, a combined left-right approach may become indispensable. For the resection of tumors near the inferior vena cava, the anterior approach is generally preferred, as it facilitates optimal exposure and visualization.

The paracaval segment, a crucial part of the caudate lobe, is widely recognized as Couinaud's segment IX. It is strategically positioned behind segment IV, essentially the epicenter of the liver's anatomy. Its dorsal surface is in intimate contact with the inferior vena cava, while its lower boundary is closely aligned with the first hepatic port. The cephalic end of this segment is contiguous with the origins of the middle and right hepatic veins, and its ventral aspect is in direct apposition to the main trunk of the middle hepatic vein. Given its concealed location and its adjacency to the liver's principal vascular structures, surgical interventions in this area are inherently risky and technically challenging. Historically, surgical procedures targeting the paracaval segment of the caudate lobe have predominantly utilized laparoscopic anterior or right-sided approaches^8,9,10. There is a dearth of literature on left-sided approaches, likely due to the profound depth of this region and the restricted field of view from the left, compounded by the intricate vascular architecture in the vicinity. Such complexities demand that the operating surgeon possess a profound understanding of anatomy and a wealth of surgical expertise. Advancements in three-dimensional (3D) visualization reconstruction technology have enabled the creation of precise and vivid three-dimensional liver models¹¹. These models offer a clear representation of the liver, the tumor, the hepatic vascular system, and the spatial relationships between the liver and neighboring organs. This technology is instrumental in providing a comprehensive preoperative understanding of the liver's specific conditions, the precise location of the tumor, and the intricate interplay of the blood vessels.

In this paper, we introduce an innovative surgical strategy: leveraging preoperative three-dimensional assessments and employing a laparoscopic left-sided approach for the excision of tumors in the paracaval region. This approach aims to enhance surgical precision and safety, capitalizing on the detailed anatomical insights provided by modern imaging techniques.

A 30-year-old female patient was admitted to Zhujiang hospital with an incidental finding of a space-occupying lesion in the liver, detected over a month ago. Enhanced computed tomography (CT) scans revealed a mass with a low-density shadow, measuring approximately 37 mm x 34 mm. Preliminary diagnoses included focal nodular hyperplasia or hepatic adenoma, which require further differentiation (Figure 1). Preoperative three-dimensional visualization reconstruction is depicted in Figure 2. The patient's complete blood count, coagulation profile, and liver function tests were all within normal limits. She had no significant medical history, and preoperative assessments confirmed no contraindications to surgery. Given the potential risk of malignancy associated with hepatic adenomas, the surgeons engaged in detailed discussions with the patient and her family, ensuring they were fully informed. After a thorough understanding of the surgical risks and the possible therapeutic outcomes, the patient and her family made an informed decision to proceed with the surgical treatment. They have provided consent by signing the surgical informed consent form, demonstrating their clear understanding of the procedure and commitment to the patient's health and well-being.

Protocol

The surgical procedure received clearance from the Ethics Committee at Zhujiang Hospital, Southern Medical University. Furthermore, the patient and her family provided informed consent for publicly sharing information and data pertinent to the treatment process. This ensures transparency and respects the patient's autonomy in the medical decision-making process.

1. Preoperative preparation

1. Have the patient fast for 8 h and refrain from drinking for 4 h before surgery.
2. Administer general anesthesia and perform endotracheal intubation¹².
   NOTE: Evaluate the effectiveness of anesthesia by assessing the patient's condition both post-anesthesia and intraoperatively. Key indicators include achieving a complete block of sensation, requiring no additional medication during the procedure, and maintaining stable vital signs throughout the surgery.
3. Disinfect the surgical area, from the nipples to the pubic symphysis and the upper third of the thighs, with iodine tincture three times, extending to the mid-axillary line.

2. Surgical technique

1. Place the patient supine with legs apart, head elevated, and a 15° tilt to the right.
2. Establish pneumoperitoneum with a Veress needle¹³. Set the pneumoperitoneum pressure to 12-14 mmHg (1 mmHg = 0.133 kPa).
3. Make a 1 cm incision with a No.10 surgical scalpel blade at the umbilical edge for an observation port, with a 10 mm trocar inserted (see Table of Materials).
   1. Insert the trocars, measuring 5 mm and 10 mm in diameter, at the following anatomical landmarks: 2 cm below the rib edge along the right anterior axillary line, 8 cm below the rib edge along the right midclavicular line, and 2 cm and 6 cm below the rib edge along the left midclavicular line, respectively (Figure 3).
4. Perform the initial laparoscopic assessment to determine the feasibility of a left-sided approach to caudate lobe resection. Observe the degree of intraperitoneal adhesion of the omentum, the surface texture of the liver, and the position of the left and right triangular ligaments and falcate ligaments.
5. Use the ultrasonic scalpel (see Table of Materials) to transect the falciform ligament, revealing the gallbladder triangle. Subsequently, ligate the cystic duct and dissect the gallbladder.
6. Use the ultrasonic scalpel to clear the small omental foramen, expose the hepatic hilum, and allow for the establishment of a hepatic hilar occlusion tape.
7. Flip the right liver lobe to expose the inferior vena cava, and ligate and transect the hepatic short veins with 3-0 Hem-o-lok (see Table of Materials)(Figure 4).
8. Expose the Spiegel area of the caudate lobe, followed by hepatic hilar occlusion, and then transect the liver parenchyma along the caudate lobe notch using the ultrasonic scalpel (Figure 5).
9. Use the ultrasonic scalpel and operating forceps to resect liver parenchyma to expose the tumor adjacent to the inferior vena cava (Figure 6 and Figure 7).
10. Carefully dissect the tumor, use an ultrasonic scalpel with freeze gear to coagulate small veins, and expose the middle hepatic vein (Figure 8).
11. Expose and ligate the portal vein to the right caudate lobe with 3-0 Hem-o-lok, followed by tumor mobilization (Figure 9, Figure 10, and Figure 11).
12. Use bipolar electrocoagulation for hemostasis and specimen retrieval. Use 800 mL of 0.9% NaCl solution to irrigate the abdominal cavity (Figure 12) and close with the drainage tube placed inside the abdominal cavity (see Table of Materials).
13. Close the wound layer by layer using non-absorbable suture material (see Table of Materials).

3. Postoperative nursing and monitoring

1. Within the first 24 h post-surgery, perform cardiac monitoring (see Table of Materials) and provide continuous low-flow oxygen therapy at 3 L/min, closely monitoring vital signs.
2. On the first postoperative day, give the patient a semi-solid diet and instruct the patient to perform turning and in-bed exercises.
   NOTE: Postoperative care includes hepatoprotective, anti-infective, anti-hemorrhagic, analgesic, albumin, and gastroprotective treatments.
3. Monitor the drainage tubes for color, volume, and changes in bilirubin levels. Remove the drainage tube once bilirubin levels return to normal and drainage is less than 50 mL.

Results

The surgery (Video 1) lasted for 372 min with a blood loss of 300 mL, and no blood transfusion was required. There were five instances of hepatic portal occlusion totaling 70 min. The patient experienced no postoperative complications and had a smooth recovery, staying in the hospital for 8 days post-surgery. Pathological examination indicated focal nodular hyperplasia (FNH) of the liver. The level of bilirubin in the drainage fluid decreased from 30.1 µmol/L on the third postoperative day to 21.4 &...

Discussion

The liver is a crucial organ involved in metabolism, immune function, and detoxification¹⁴. Hepatocytes, the liver's primary cells, are typically stable but can become unstable when triggered, initiating the regeneration of liver tissue. Following liver resection, insufficient residual liver volume may lead to severe postoperative complications such as acute liver failure. Thus, rigorous evaluation of liver function post-hepatectomy is of paramount importance^15,

Materials

Name	Company	Catalog Number	Comments
Absorbable hemostat	Ethicon, LLC	W1913T
Disposable spiral negative pressure drainage pipeline	Jiangsu Aiyuan Medical Technology Corp	424280	Drainage of abdominal residual fluid
Disposable trocar	Kangji Medica	10004, 10006
Electrocardiographic monitor	Philips Goldway (SHENZHEN) Industrial, Inc	UT4000B	Postoperative ECG monitoring
Laparoscopic system	Olympus	WM-NP2
Non-absorbable polymer ligation clips (Hem-o-lok)	Teleflex Medical	544230
Ultrasound scalpel	Johnson	GEN11	Tools for liver resection
Vicryl rapide	Ethicon, LLC	3-0, VCP345H 90010	Suture incision and Trocar hole
Video system	Lenovo	GK309