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

Summary

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.

Abstract

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.

Introduction

Hepatocellular carcinoma is a common cancer; it is the sixth most common neoplasm in adults and the third leading cause of cancer death worldwide, and its incidence is predicted to rise in the future¹. Surgical resection, ablative electrochemical therapy, transarterial chemoembolization, systemic therapy such as sorafenib, and transplantation have been reported to be effective treatment modalities for liver cancer^2,3. Of these options, surgical resection of hepatocellular carcinoma (HCC) is considered the primary curative treatment since the tumor can be completely removed rather than l....

Protocol

The procedure was reviewed and approved by the Clinical Research and Application Ethics Committee of the Second Affiliated Hospital of Guangzhou Medical University. The content and methods of the research are in line with medical ethics norms and requirements. The patient was informed of the purpose, background, process, risks, and benefits of the study prior to surgery. The patient understood that participation in this study was voluntary and signed informed consent.

1. Patient position.......

Discussion

Anatomic hepatectomy is a procedure that can simultaneously remove the lesion and the liver segments along with the corresponding veins and has been considered an ideal method for treating liver cancer^23,24,25,26. With technological innovation, anatomic liver resection with laparoscopic technology has developed rapidly as an alternative to conventional open liver resection and is now widely acc.......

Materials

Name	Company	Catalog Number	Comments
30° Laparoscopy	Olympus Corporation	CV-190
Harmonic Ace Ultrasonic Surgical Devices	Ethicon Endo-Surgery, LLC	HAR36
Laparoscopic ultrasonography	Hitachi	Arietta 60
Monopole electrocoagulation	Kangji Medical	/
Nasogastric tube	Pacific Hospital Supply Co. Ltd	I02705
Powered plus stapler	Ethicon Endo-Surgery, LLC	PSEE60A
Single lumen ureter	Well Lead Medical CO, LTD	14F,8F
Trocar	Surgaid Medical	NPCM-100-1-10
Vascular clips	Teleflex Medical	544243