This work was supported by grants from the Science and Technology Project of Guangzhou City (202102010090) and the Guangzhou Municipal Health and Family Planning Commission (grant No.20201A001086 to Dr. Tang).

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...

<ol>
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P., Shi, N., Jian, Z. X., Jin, H. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Research+progression+and+application+of+Laennec+capsule+in+liver.">Research progression and application of Laennec capsule in liver.</a> Zhonghua Wai Ke Za Zhi. 58 (8), 646-648 (2020).</li><li>Yu, H. 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=Identification+of+the+anterior+sectoral+trunk+with+particular+reference+to+the+hepatic+Hilar+plate+and+its+clinical+importance.">Identification of the anterior sectoral trunk with particular reference to the hepatic Hilar plate and its clinical importance.</a> Surgery. 149 (2), 291-296 (2011).</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=Hepatic+resection+using+Glissonean+pedicle+transection.">Hepatic resection using Glissonean pedicle transection.</a> Nihon Geka Gakkai Zasshi. 99 (4), 245-250 (1998).</li><li>Zhou, X. P., 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=Micrometastasis+in+surrounding+liver+and+the+minimal+length+of+resection+margin+of+primary+liver+cancer.">Micrometastasis in surrounding liver and the minimal length of resection margin of primary liver cancer.</a> World Journal of Gastroenterology. 13 (33), 4498-4503 (2007).</li><li>Makuuchi, M., Hasegawa, H., Yamazaki, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasonically+guided+subsegmentectomy.">Ultrasonically guided subsegmentectomy.</a> Surgery, Gynecology and Obstetrics. 161 (4), 346-350 (1985).</li><li>Kang, K. J., Ahn, K. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anatomical+resection+of+hepatocellular+carcinoma:+A+critical+review+of+the+procedure+and+its+benefits+on+survival.">Anatomical resection of hepatocellular carcinoma: A critical review of the procedure and its benefits on survival.</a> World Journal of Gastroenterology. 23 (7), 1139-1146 (2017).</li><li>Hasegawa, K., 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+impact+of+anatomic+resection+for+hepatocellular+carcinoma.">Prognostic impact of anatomic resection for hepatocellular carcinoma.</a> Annals of Surgery. 242 (2), 252-259 (2005).</li><li>Yamazaki, O., 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=Comparison+of+the+outcomes+between+anatomical+resection+and+limited+resection+for+single+hepatocellular+carcinomas+no+larger+than+5+cm+in+diameter:+A+single-center+study.">Comparison of the outcomes between anatomical resection and limited resection for single hepatocellular carcinomas no larger than 5 cm in diameter: A single-center study.</a> Journal of Hepato-Biliary-Pancreatic Sciences. 17 (3), 349-358 (2010).</li><li>Yan, Y., Cai, X., Geller, D. A. <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+status.">Laparoscopic liver resection: A review of current status.</a> Journal of Laparoendoscopic &amp; Advanced Surgical Techniques A. 27 (5), 481-486 (2017).</li><li>Nguyen, K. T., Gamblin, T. C., Geller, D. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=World+review+of+laparoscopic+liver+resection-2,804+patients.">World review of laparoscopic liver resection-2,804 patients.</a> Annals of Surgery. 250 (5), 831-841 (2009).</li><li>Kang, W. 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=Long-term+results+of+laparoscopic+liver+resection+for+the+primary+treatment+of+hepatocellular+carcinoma:+Role+of+the+surgeon+in+anatomical+resection.">Long-term results of laparoscopic liver resection for the primary treatment of hepatocellular carcinoma: Role of the surgeon in anatomical resection.</a> Surgical Endoscopy. 32 (11), 4481-4490 (2018).</li><li>Berardi, 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=Parenchymal+sparing+anatomical+liver+resections+with+full+laparoscopic+approach:+Description+of+technique+and+short-term+results.">Parenchymal sparing anatomical liver resections with full laparoscopic approach: Description of technique and short-term results.</a> Annals of Surgery. 273 (4), 785-791 (2021).</li><li>Ome, Y., Honda, G., Doi, M., Muto, J., Seyama, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+anatomic+liver+resection+of+segment+8+using+intrahepatic+Glissonean+approach.">Laparoscopic anatomic liver resection of segment 8 using intrahepatic Glissonean approach.</a> Journal of the American College of Surgery. 230 (3), e13-e20 (2020).</li><li>Kokudo, T., 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=Liver+resection+for+hepatocellular+carcinoma+associated+with+hepatic+vein+invasion:+A+Japanese+nationwide+survey.">Liver resection for hepatocellular carcinoma associated with hepatic vein invasion: A Japanese nationwide survey.</a> Hepatology. 66 (2), 510-517 (2017).</li><li>Kokudo, T., 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=Surgical+treatment+of+hepatocellular+carcinoma+associated+with+hepatic+vein+tumor+thrombosis.">Surgical treatment of hepatocellular carcinoma associated with hepatic vein tumor thrombosis.</a> Journal of Hepatology. 61 (3), 583-588 (2014).</li><li>Pesi, B., 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=Liver+resection+with+thrombectomy+as+a+treatment+of+hepatocellular+carcinoma+with+major+vascular+invasion:+Results+from+a+retrospective+multicentric+study.">Liver resection with thrombectomy as a treatment of hepatocellular carcinoma with major vascular invasion: Results from a retrospective multicentric study.</a> American Journal of Surgery. 210 (1), 35-44 (2015).</li><li>Neuhaus, P., 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=Extended+resections+for+Hilar+cholangiocarcinoma.">Extended resections for Hilar cholangiocarcinoma.</a> Annals of Surgery. 230 (6), 808-818 (1999).</li><li>Becker, T., 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=Surgical+treatment+for+Hilar+cholangiocarcinoma+(Klatskin's+tumor).">Surgical treatment for Hilar cholangiocarcinoma (Klatskin's tumor).</a> Zentralblatt fur Chirurgie. 128 (11), 928-935 (2003).</li><li>Bednarsch, 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=Left+versus+right-sided+hepatectomy+with+hilar+en-bloc+resection+in+perihilar+cholangiocarcinoma.">Left versus right-sided hepatectomy with hilar en-bloc resection in perihilar cholangiocarcinoma.</a> HPB. 22 (3), 437-444 (2020).</li></ol>

The authors have no conflicts of interest or financial ties to disclose.

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 cancer23,24,25,26. 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...

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 cancer2,3. Of these options, surgical resection of hepatocellular carcinoma (HCC) is considered the primary curative treatment since the tumor can be completely removed rather than limited4.
Laparoscopic surgery, a minimally invasive technique with fewer perioperative complications compared to open resection5, has made great progress worldwide and has steadily become an important surgical method for liver surgery6,7,8. However, in laparoscopic liver resection, the surgeon&#39;s inability to recognize the tumor margins under direct vision and the fear of not being able to ensure laparoscopic hemostasis have discouraged most liver surgeons from attempting this demanding procedure. In 1960, Lin et al. reported a case of right hepatic lobectomy with intrahepatic portal vein pedicle ligation9. In 1986, Takasaki also described Glisson&#39;s pedicle transect hepatectomy, named extrathecal dissection10. In 1991, Reich et al. applied laparoscopic resection of benign liver tumors and completed the world&#39;s first laparoscopic hepatectomy11. Since then, anatomical hepatectomy has gradually entered the public view while providing technical support for laparoscopic hepatectomy. However, in the case in the present study, the lower end of the tumor reached the cystic plate, and simple traditional anatomic resection could not guarantee an R0 resection, but the management of such cases has rarely been reported in detail. In 1999, Neuhaus et al. proposed the principle of total portal vein resection, which proved to be a good prognostic indicator, increasing the chance of R0 resection12. Accordingly, with a new understanding of liver anatomy, we advanced a new approach called &#34;en bloc concept combined with anatomic resection&#34;, which is depicted in this video protocol.
In this study, the patient was a 67-year-old female admitted to our hospital in August 2021 with mild upper abdominal pain for 1 month. Her medical history was notable for hypertension and diabetes. Abdominal contrast-enhanced computed tomography revealed a mass with heterogeneous enhancement located at segment 4 of the liver, with a size of 247 mm x 54 mm x 50 mm. The lower end of the mass had reached the cystic plate, and the possibility of gallbladder invasion could not be ruled out (Figure 1). The Child-Pugh liver function13 was grade A, and the ICG clearance rate14,15 R15 was 5.1% (&#60;10%). The patient was classified as stage A according to the BCLC algorithm16 and stage IB according to the CNLC algorithm17. After a multidisciplinary meeting, it was decided that her treatment should be laparoscopic left lobe resection of the liver and cholecystectomy. The concept of en bloc resection combined with anatomic hepatic resection in laparoscopy was adopted to eliminate the enormous liver mass totally.

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	<tbody>
		<tr>
			<td>30&#176; Laparoscopy</td>
			<td>Olympus Corporation</td>
			<td>CV-190</td>
			<td></td>
		</tr>
		<tr>
			<td>Harmonic Ace Ultrasonic Surgical Devices</td>
			<td>Ethicon Endo-Surgery, LLC</td>
			<td>&#160;HAR36</td>
			<td></td>
		</tr>
		<tr>
			<td>Laparoscopic ultrasonography</td>
			<td>Hitachi</td>
			<td>Arietta 60</td>
			<td></td>
		</tr>
		<tr>
			<td>Monopole electrocoagulation</td>
			<td>Kangji Medical</td>
			<td>/</td>
			<td></td>
		</tr>
		<tr>
			<td>Nasogastric tube</td>
			<td>Pacific Hospital Supply Co. Ltd</td>
			<td>I02705</td>
			<td></td>
		</tr>
		<tr>
			<td>Powered plus stapler</td>
			<td>Ethicon Endo-Surgery, LLC</td>
			<td>PSEE60A</td>
			<td></td>
		</tr>
		<tr>
			<td>Single lumen ureter</td>
			<td>Well Lead Medical CO, LTD</td>
			<td>14F,8F</td>
			<td></td>
		</tr>
		<tr>
			<td>Trocar</td>
			<td>Surgaid Medical</td>
			<td>NPCM-100-1-10</td>
			<td></td>
		</tr>
		<tr>
			<td>Vascular clips</td>
			<td>Teleflex Medical</td>
			<td>544243</td>
			<td></td>
		</tr>
	</tbody>
</table>

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.

The duration of the operation was 255 min, no complications were observed during the operation, and the estimated blood loss was less than 20 mL. The operation was not converted to open surgery, and no postoperative complications were seen. Liver segment 2, liver segment 3, and liver segment 4 (including the gallbladder) were resected anatomically, and the MHV as well as its tributaries (V5v, ventral branch of the fifth segment of the hepatic vein; V8v, ventral branch of the eigth segment of the hepatic vein) were comple...

Watch this Scientific Journal Video about Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy at JoVE.com

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

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 ...

With this minimally invasive method obtaining a wide range of negative margins is easier and avoids the spread of tumor tissue. This method helps in maximizing R0 resection, and avoiding perioperative complications. This technique can be used in laparoscopic hepatic resection surgeries involving resection of four to five segments.Because this minimally invasive surgical method requires experience in open surgeries, appropriate open surgery training is recommended. After preparing the patient for the procedure, pull the fundus of the gallbladder upward, and use a harmonic scalpel for Calot's Triangle Dissociation. Take care to ligate the cystic duct and artery with medium-sized hemostatic clips.Avoid cutting the gallbladder and leave the gallbladder in situ primarily. Carefully separate the left coronary and triangular ligaments, avoiding injury to the adjacent phrenic vein branches. Then prepare for hepatic inflow occlusion by accessing from left to right behind the hepatoduodenal ligament through a sling removed from the attached 14F single human catheter.After ligating the left hepatic artery with medium-sized vascular clips ensure that the first porta hepatis has been blocked with the single lumen catheter to prevent unexpected bleeding during the mobilization of the left hepatic pedicle. Gently lift the inferior edge of the liver free the left glissonean pedicles by the Laennec membrane and hilar plate gap, and then prepare a tourniquet system to block the left hepatic inflow by inserting an 8F single human catheter through the left glissonean pedicle. After releasing the first porta hepatis, block the left hepatic pedicle by clamping the single lumen catheter with a hemostatic clip which will be stapled after parenchyma transection.Follow the dividing line to seek and mark the projection positions of the middle hepatic veins with laparoscopic ultrasonography. Pay attention to mapping the location and trajectories of the vital intrahepatic vessel, especially those on the expected transverse plane of the liver parenchyma. Drag the gallbladder's fundus using an ultrasonic scalpel with an assistant's help, and transect the parenchyma from the foot to the head side along the middle hepatic vein.Trigger the ultrasonic scalpel early to reduce hepatic parenchymal bleeding effectively, and do not clamp the scalpel tip to avoid vessel damage. Secure the large intrahepatic vessels and bile ducts found during the parenchymal resection with 2-O sutures if necessary. Now, expose the vascular pedicles inflowing into segments 4A, 4B, and the left hepatic vein in the cutting line.Then expose the whole middle hepatic vein, and its tributaries fully, and dissect the roots of the left and middle hepatic vein later. Use monopolar electrocoagulation for hemostasis when bleeding spots are found on the cut surface. Wrap the resected left hepatic lobe in a plastic bag.Take it out through a four centimeter long incision in the lower abdomen, and place two drainage tubes. The resected liver tissue specimen with an attached gall bladder is shown. The paraffin pathology of the tumor confirmed hepatocellular carcinoma which was 2.2 centimeters from the negative liver resection margin.No abnormal heterogeneous enhancement was observed in the remaining liver parenchyma after six days and one month post-surgery. It is important to avoid cutting the gallbladder, and leaving the gallbladder in suture primarily. Also free the left Glissonean pedicles by the gap between the Laennec membrane and the hilar plate.This method can also be used for hepatic portal blockade with sutures blocking the hilar of the liver. However, the blocking time is difficult to control.

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JoVE Journal

Cancer Research

953 Görüntüleme.  the Second Affiliated Hospital of Guangzhou Medical University. Bu minimal invaziv yöntemle çok çeşitli negatif marjlar elde etmek daha kolaydır ve tümör dokusunun yayılmasını önler. Bu yöntem, R0 rezeksiyonunu maksimize etmeye ve perioperatif komplikasyonlardan kaçınmaya yardımcı olur. Bu teknik, dört ila beş segmentli rezeksiyonu içeren laparoskopik hepatik rezeksiyon ameliyatlarında kullanılabilir.Bu minimal invaziv cerrahi yöntem açık ameliyatlarda deneyim gerektirdiğinden, uygun açık cerrahi eğitimi önerilir. Hasta...