advanced laparoscopic left lateral sectionectomy without controlled low central venous pressure in liver surgery

Laparoscopic Sectionectomy Using Ligamentum Teres for Bloodless Hepatectomy

Laparoscopic techniques are extensively used in liver surgery and are considered safe and effective. Compared with open surgery, laparoscopic left lateral sectionectomy (LLLS) offers several advantages, including a reduced overall complication rate, shorter postoperative hospitalization, and decreased blood loss1. In the traditional LLLS procedure, the parenchyma is dissected using a harmonic scalpel, starting on the upper liver surface, proceeding from front to back, taking layers 2-3 mm deep ventral and dorsal to the level of the LHV, followed by direct dissection of the left outer lobe hepatic hilum with a staple2. This method may lead to injury of the hepatic parenchyma and veins, thereby increasing the risk of bleeding. The controlled low central venous pressure (CLCVP) technique is often employed in traditional LLLS procedures to mitigate intraoperative bleeding3. However, in patients with concurrent cardiovascular and cerebrovascular diseases, anesthesiologists may opt to avoid using the CLCVP technique to prioritize the perfusion of vital organs4. Herein, we present a standardized procedure for LLLS that does not rely on the CLCVP technique but effectively manages intraoperative bleeding. The key components of the procedure are as follows: (1) utilizing the ligamentum teres hepatis (LTH) approach to control the Glissonian pedicles for segments 2/3; (2) determining the transection plane of the liver based on anatomical landmarks such as the falciform ligament, umbilical fissure vein (UFV), and the canal of Arantius; and (3) using the UFV as a guide for hepatic parenchymal transection to enhance accessibility to the root of the left hepatic vein. The rationale for this technique, which is guided by anatomical landmarks such as the Glissonian pedicle and intrahepatic veins (e.g., UFV), enables more precise lobular and segmental resections while reducing the risk of hemorrhage5. This procedure is straightforward and easy to disseminate and learn. Xie et al.6 and Prof. Sugioka et al.7 have highlighted the safety, effectiveness, simplicity, and anatomical correctness of the LTH approach in hepatectomy procedures. We introduced the LLLS procedure guided by LTH and UFV to further improve the surgical technique.
In this study, we present a representative case to elucidate the procedural steps involved. A 74-year-old male patient presented with chronic upper abdominal pain that had persisted for 3 months. Pre-operative magnetic resonance imaging (MRI) revealed left intrahepatic bile duct stones and localized cystic dilatation of the bile ducts (Figure 1A,B). Additionally, the patient had a history of two cerebral infarctions. Head MRI indicated multiple ischemic and infarct lesions in various brain regions, including the bilateral periventricular regions, basal ganglia, corona radiata, brainstem, and frontal lobes. Notably, lesions in the left basal ganglia and adjacent parts of the right lateral ventricle softened with gliosis. The patient&#39;s Child-Pugh score was 5 (Grade A), and indocyanine green (ICG) retention at 15 min was 6.5%. Based on the radiological features, the patient was diagnosed with left intrahepatic bile duct stones. Subsequently, the patient underwent LLLS.

Author Spotlight: Advancing Hepatobiliary and Pancreatic Tumor Treatment with Minimally Invasive Surgical Techniques

Laparoscopic Left Lateral Sectionectomy: Guided by the Ligamentum Teres Hepatis and the Umbilical Fissure Vein

My research focuses on minimally invasive surgical treatments for hepatobiliary and pancreatic tumors. Guided by ligamentum teres hepatis and umbilical fissure vein, this laparoscopic left lateral sectionectomy procedure effectively controls intraoperative bleeding, even in the absence of controlled low central venous pressure. These attributes offer the potential benefit for patients with cardiovascular or cerebrovascular conditions.Advanced imaging modalities, such as indocyanine green fluorescence imaging, can provide real-time visualization of biliary anatomy, aiding in surgical planning and decision making. The advantage of our technique is that it avoids hepatic hilar dissection. Second, during liver parenchymal dissection, we utilize the intrahepatic anatomic landmark of the umbilical fissure vein as a guide to prevent loss of direction.

Advanced Laparoscopic Left Lateral Sectionectomy Without Controlled Low Central Venous Pressure in Liver Surgery

To begin the left liver lobe mobilization, use an ultrasonic scalpel to dissect the hepatic round ligament and falciform ligament of the anesthetized patient. Then, completely divide the triangular ligament and coronary ligament to reveal the root of the left hepatic vein. Next, employ a grasper posterior to the hepatic pedicle via the foramen of Winslow to facilitate the placement of a cotton tape.Extract the ends of the cotton tape through a five-millimeter port trocar under the guidance of the grasper. After removing the five-millimeter trocar, thread one end of the cotton tape through a suction tube and advance it into the abdominal cavity up to the hepatic pedicle. Maintain the external end of the cotton tape outside the patient's body.Next, using an ultrasonic scalpel, dissect the superficial peritoneum along the left side of the ligamentum teres hepatis. Dissect the Glissonean pedicles for segments 2 and 3 from the ventral to the dorsal side and excise them using clips or a stapler. Then, dissect the hepatic parenchyma along the umbilical fissure vein within the hepatic parenchyma to identify the root of the left hepatic vein.Divide the small vessels with the ultrasonic scalpel. After dividing the large vessels, transect the left hepatic vein with a stapler. Finally, utilize bipolar electrocoagulation forceps to coagulate the hemorrhagic points.The CT scan on postoperative day 5 showed no blood or fluid accumulation in the liver section. Histological examination revealed intrahepatic bile duct stones, inflammatory cell infiltration, and small bile duct proliferation in the porta hepatis region. The postoperative incision healed satisfactorily without infection.

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Research

JoVE Journal

Medicine

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.

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 ...