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

Summary

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.

Abstract

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.

Introduction

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 outcomes^1,2,3,4. 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 feasibility^2,5,6,7. 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 '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. Machado et al. and Topal et al. reported the feasibility and safety of the laparoscopic intrahepatic Glissonian approach^8,9,10. 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 'ultrasonic scalpel mimic CUSA' technique in 2019¹¹, which has been shown to reduce intraoperative blood loss and operative time^11,12.

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). 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'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.

Protocol

The protocol follows the guidelines of Kwong Wah Hospital's human research ethics committee.

1. Pre-operative workup

1. Check triphasic CT scans to evaluate the extent of disease and vascular anatomy.
2. 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.
3. 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.

2. Anesthesia

1. Administer pre-operative antibiotics, typically 1.2 g of amoxicillin and clavulanic acid, intravenously on induction of anesthesia.
2. Perform deep venous thrombosis prophylaxis with a sequential compression device and compression stockings¹⁵.
3. Place an arterial line and a central venous line.
4. Control low central venous pressure to 3-8 mmHg¹⁶. An anesthetist performs this.

3. Patient positioning

1. Position the patient in the Lloyd-Davis position on a split-leg table.
2. Set the theatre as depicted in Figure 2, allowing the surgeon to stand between the patient'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.
3. Elevate the patient to 30° left lateral position with a pillow during the operation.

4. Port site insertion and the laparoscope

1. Establish access into the intraabdominal cavity with a sub-umbilical incision by open Hasson Technique¹⁷.
2. Place the remaining ports as depicted in Figure 3.
3. Place a 12 mm port in the right upper quadrant along the midclavicular line.
4. 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).

5. Operative steps

1. Mobilization of the whole right lobe of the liver
   1. Expose the root of the right hepatic vein superiorly.
      1. Complete division of triangular ligament until bare area exposed.
      2. Expose the groove between the right hepatic veins and the common trunk of the middle and left hepatic veins.
   2. Expose the root of IVC inferiorly.
      1. Incise inferior peritoneal attachment and drop the adrenal gland to the retroperitoneum.
      2. Divide the short hepatic veins and vena cava ligament until the inferior border of the right hepatic vein is seen.
2. Right posterior pedicle control with intrahepatic Glissonian approach¹⁸.
   1. Dissect along the superior border of the right posterior Glissonian pedicle along the Rouviere sulcus while keeping the Laennec capsule intact.
   2. Transect the caudate process to expose the inferior margin of the right posterior Glissonian pedicle.
   3. Dissect along the inferior border of the right posterior Glissonian pedicle along the Rouviere sulcus while keeping the Laennec capsule intact.
   4. Control the right posterior pedicle temporarily with a bulldog clamp.
3. Determination of the transection plane along the ischaemic line
   1. Perform Intraoperative ultrasonography (USG) to identify the course of the right hepatic vein¹⁹.
   2. 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.
   3. Mark the rest of the transection line along the ischaemic line with diathermy.
4. Pringle maneuver
   1. Prepare intracorporeal tourniquet for laparoscopic Pringle maneuver by Huang's Loop using a shortened Foley catheter²⁰.
5. Parenchymal transection
   1. Open the liver capsule with an ultrasonic scalpel along the planned transection line.
   2. Perform subsequent deep parenchymal transection with the 'ultrasonic scalpel mimic CUSA' technique¹².
      1. Keep both arms of the ultrasonic scalpel open.
      2. Use the active blade of the ultrasonic scalpel to dissect the tissue.
      3. Activate maximum and move the active blade in a horizontal swinging motion parallel to the vasculobiliary structure.
      4. Dissect the parenchyma while exposing the individual intrahepatic vessels and leaving them intact.
      5. Use a suction device with the left hand constantly to keep the surgical field dry.
      6. Divide small vessels with the ultrasonic scalpel.
      7. Divide large vessels or pedicle structures between plastic clips (Table of Materials) or metal clips.
6. Right posterior pedicle transection
   1. Encircle the right posterior pedicle with vascular tape.
   2. Transect the right posterior pedicle with a vascular stapler.
7. Right hepatic vein transection
   1. Transect the right hepatic vein with a vascular stapler.
8. Bleeding control
   1. The right posterior pedicle is temporarily controlled as a form of partial Pringle's maneuver during parenchymal transection. Meticulous dissection and identification of intrahepatic vessels are critical. Divide portal and hepatic venules with clips or ultrasonic scalpel.
   2. Use bipolar diathermy for bleeding with simultaneous suctioning to clear the surgical field.
   3. 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.
   4. Use a suture to secure bleeding from large veins or arteries.

6. Specimen retrieval

1. The specimen is put into a plastic bag and retrieved through the Pfannenstiel incision.

Results

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...

Discussion

The critical components of the surgery include the intrahepatic Glissonian approach for inflow control, a 'ultrasonic scalpel mimic CUSA' 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

Materials

Name	Company	Catalog Number	Comments
3D ENDOEYE Flex	Olympus	LTF-S190-10-3D	Flexible tip laparoscopic camera
5 mm ROBI Bipolar Grasping Forceps	KARL STORZ	38851 ON	atraumatic, fenestrated forceps
AESCULAP Challenger Ti-P	Barun	PL520L	Pneumatic driven multi-fire clip applicator. 5 mm metal clips
Endo GIA Reloads with Tri-Staple Technology, 30 mm, Tan colour	Medtronic	SIG30AVM	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.
Endo GIA Ultra Universal Stapler	Medtronic	EGIAUSTND	Manual stapler that compresses tissue while it simultaneously lays down a staple line and transects the tissue
HARMONIC ACE+7 Shears	Ethicon	HARH36	Curved tip, energy sealing and dissecting, diameter 5 mm, length 36 cm
Hem-o-lok Clips L	Weck Surgical Instruments, Teleflex Medical, Durham, NC	544240	Vascular clip 5–13 mm Size Range
Hem-o-lok Clips ML	Weck Surgical Instruments, Teleflex Medical, Durham, NC	544230	Vascular clip 3–10 mm Size Range
Hem-o-Lok Polymer Ligation System	Weck Surgical Instruments, Teleflex Medical, Durham, NC	544965
Profocus 2202 Ultraview 800	BK Medical	N/A	Intraoperative Ultrasonography