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 positioning, instruments, and port placement
<ol>
	<li>Place the patient in the supine and 30&#176; reverse Trendelenburg position on the operating table, and subsequently tilt 30&#176; to the right during the procedure, with the surgeon performing from the right side.</li>
	<li>Use the five-port technique during the procedure, with three 10 mm trocars, one 5 mm trocar, and one 12 mm trocar for retraction and specimen retrieval. Then, assemble the following hemostatic devices: 30&#176; laparoscope, laparoscopic ultrasonography device, and basic laparoscopic instruments, including a single lumen catheter, a harmonic scalpel, a monopole electrocoagulator, a vascular clip, and a powered endoscopic cutter stapler (see Table of Materials).</li>
	<li>Administer the patient a combination of intravenous and inhalation anesthesia by giving propofol 150 mg, sufentanil 15 ug, and rocuronium bromide 50 mg intravenously, followed by endotracheal intubation 7.5 F after 90 s. 
	NOTE: The selection of the anesthetic agents and the application of intravenous and inhalation anesthesia are decided and performed by the anesthetist on a case-to-case basis.
	<ol>
		<li>During the parenchymal transection, lower the central venous pressure by 3-5 cm H2O to reduce hepatic venous bleeding while limiting the fluid replacement as much as possible. Place a lumen catheter and nasogastric tube (see Table of Materials) in the bladder and stomach for urinary volume recording and decompression.</li>
	</ol>
	</li>
	<li>Routinely place a preoperative arterial line and a central venous (internal jugular vein) catheter. Use a 10 mm trocar for the observation port 2 cm below the umbilicus. Then, establish pneumoperitoneum by insufflating carbon dioxide, and maintain the intra-abdominal pressure at 12-14 mmHg (1 mmHg, 1/4 0.133 kPa).</li>
	<li>Place the other four trocars in the following locations: the 5 mm trocar in the right anterior axillary line, the 12 mm trocar in the right midclavicular line under the costal margin, the 10 mm trocar in the left anterior axillary line, and the 10 mm trocar in the left midclavicular line under the costal margin (Figure 2).</li>
</ol>
2. Surgical technique
<ol>
	<li>Pull the fundus of the gallbladder upward, and use a harmonic scalpel (see Table of Materials) for Calot&#39;s triangle18&#160;dissociation. Take care to ligate the cystic duct and artery with medium-sized hemostatic clips, do not cut the gallbladder, and leave the gallbladder in situ primarily (Figure 3).</li>
	<li>Segment the round and falciform ligaments with the harmonic scalpel. Separate the left coronary and triangular ligaments carefully, avoiding injury to the adjacent phrenic vein branches (Figure 4). Then, incisethe hepatogastric ligaments medially 10 mm into the lesser sac.</li>
	<li>Access from left to right behind the hepatoduodenal ligament through a sling removed from the attached 14 F single-lumen catheter to prepare for hepatic inflow occlusion (Figure 5).</li>
	<li>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.
	<ol>
		<li>Gently lift the inferior edge of the liver, free the left Glissonean pedicles by the gap of the Laennec membrane19 and Hilar plate20 (Figure 6), and then prepare a tourniquet system to block the left hepatic inflow by inserting an 8 F single lumen catheter through the left Glissonean pedicle21 (Figure 7).</li>
	</ol>
	</li>
	<li>After releasing the first porta hepatis, block the left hepatic pedicle by clamping the single lumen catheter with a hemostatic clip (Figure 8), which will be stapled after parenchyma transection. Determine the border between the left and right hepatic lobes by identifying ischemia of the left hepatic lobe.
	<ol>
		<li>Following the dividing line, 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 vessels, especially those located on the expected transverse plane of the liver parenchyma (Figure 9). 
		NOTE: In this study, the ultrasound was set to color Doppler flow image (CDFI) mode, and the thin-walled vessel flowing into the inferior vena cava in the same direction as the long axis of the ultrasound probe was judged to be the MHV. Moreover, it was also located near the dividing line.</li>
	</ol>
	</li>
	<li>Mark the parenchymal transection line with an electric hook along the demarcation line on the liver surface (Figure 10). Ask the assistant to drag the fundus of the gallbladder and transect the parenchyma from the foot side to the head side along the middle hepatic vein using an ultrasonic scalpel (Figure 11).
	<ol>
		<li>Trigger the ultrasonic scalpel early to effectively reduce hepatic parenchymal bleeding, and do not clamp the tip of the scalpel to avoid vessel damage. Secure or suture the large intrahepatic vessels and bile ducts found during the parenchymal resection with 2-0 sutures if necessary.</li>
	</ol>
	</li>
	<li>Expose the vascular pedicles inflowing into segments 4a/4b and the left hepatic vein further up in the cutting line (Figure 12). Then, expose the whole MHV and its tributaries fully, and dissect the roots of the LHV and MHV later (Figure 13). Lastly, staple the inflow and outflow vessels with the powered plus stapler when exposed.</li>
	<li>Once the liver specimens have been isolated from the remaining right hepatic lobe, conduct a hemostasis and bile leakage examination along the cut surface before suturing.
	<ol>
		<li>Use monopole electrocoagulation (see Table of Materials) for hemostasis when bleeding spots are found on the cut surface (Figure 14). Wrap the resected left hepatic lobe (Figure 15) in a plastic bag, and take it out through a 4 cm long incision in the lower abdomen, followed by the placement of two drainage tubes.</li>
	</ol>
	</li>
</ol>
3. Postoperative nursing
<ol>
	<li>On the first postoperative day, discontinue the nasogastric tube, and give the patient a liquid diet.</li>
	<li>Remove the Foley catheter on postoperative day 2, and assist the patient in getting out of bed for daily activities.</li>
	<li>Finally, when the drainage is less than 50 mL per day, remove the two drainage tubes on the fourth and fifth days, respectively. Ask the patient to return to the hospital for a follow-up examination 1 month later.</li>
</ol>

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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.

<table><tbody><tr><td>30&amp;deg; 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>&amp;nbsp;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 ...

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Research

JoVE Journal

Cancer Research

1.1K Views.  the Second Affiliated Hospital of Guangzhou Medical University. 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. 

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

Application of Hemostatic Devices in Laparoscopic Hepatectomy

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. Despite its non-invasive aspect, bleeding and bile leakage occur in liver parenchyma tissue resection during the operation or in the post-operation period, indicating the requirement for high-grade hemostatic devices, such as ultrasonic surgical aspiration, bipolar electrocoagulation, etc. The lack of availability of these high-grade hemostatic devices prevents laparoscopic hepatectomy from becoming a generalized procedure in basic medical organizations. In view of the situation mentioned above, a suite of simple and easy hemostatic devices is developed in this protocol, which includes a harmonic scalpel, monopole electrocoagulation, and a single lumen catheter, to innovatively perform liver parenchyma tissue resection. First of all, the porta hepatis or hepatic pedicle is occluded intermittently by a single lumen catheter, followed by clamping for 15 min and releasing for 5 min. Subsequently, using the harmonic scalpel, clamping and crushing of the liver are done to cut off the hepatic parenchyma tissue and to reveal the intrahepatic arteries, veins, and bile ducts. Lastly, the bleeding spots are coagulated by using monopole electrocoagulation at each spot. Intrahepatic pipeline structures are then visible by using these methods, which could stop bleeding easily, reduce the incidence rate of bile leakage, and improve the safety and feasibility of laparoscopic hepatectomy. Therefore, the simple and easy hemostatic devices shown here are suitable for conducting procedures in primary medical institutions.

High-grade hemostatic devices are essential for laparoscopic hepatectomy. However, these devices are not generalized in basic medical organizations. Therefore, a suite of simple and easy hemostatic devices is shown in this article, which can make the laparoscopic hepatectomy easier to perform.

Laparoscopic hepatectomy is considered a conventional method for treating benign and malignant liver diseases because it is a minimally invasive method. ...

Laparoscopic Anterior Right Hepatectomy: A Single-Center Experience

Laparoscopic anterior right hepatectomy (LARH) has been used in some hospitals. However, data on the feasibility and safety of this procedure are still limited, due to the demanding technical requirements. The primary objective of this study was to compare the clinical outcomes of LARH with those of laparoscopic conventional right hepatectomy (LCRH) in patients with large right hepatocellular carcinoma, as well as to confirm the safety and feasibility of LARH. Furthermore, the article presents a step-by-step description of the surgical procedures for LARH to help perform this surgery in the clinic. The principle of LARH is to first prioritize the hepatic inlet duct separation while separating the right hepatic perihepatic ligament after transecting the liver. From December 2015 to June 2022, 82 patients with large right hepatocellular carcinoma (maximum tumor diameter &#8805; 5 cm), were recruited for the study. In this cohort, 54 and 28 patients underwent LARH and LCRH, respectively. The perioperative clinical data and survival outcomes of the two groups were compared. Compared with LCRH, LARH exhibited the advantages of less contact and extrusion, thereby leading to the achievement of superior results. Thus, we propose that LARH is the optimal choice for patients with large right hepatocellular carcinoma.

Here we present a step-by-step protocol for conducting laparoscopic anterior right hepatectomy and compare its clinical effects and postoperative outcomes with those of conventional hepatectomies. Analysis of the data of 82 patients with hepatocellular carcinoma revealed that laparoscopic anterior right hepatectomy had better clinical outcomes and survival rates than the conventional hepatectomy.

Laparoscopic anterior right hepatectomy (LARH) has been used in some hospitals. However, data on the feasibility and safety of this procedure are still ...

Behavior

Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ultrasound, important vascular structures, and surgeon experience. With the development of anatomical hepatectomy, visual surgery technology has gradually been applied to this type of surgery, particularly indocyanine green (ICG)-guided anatomical hepatectomy. As ICG can be specifically ingested by hepatocytes and used for fluorescence tracing, negative staining techniques have been applied according to different tumor positions. Under ICG fluorescent guidance, the surface boundary and deep resection plane can be more accurately displayed during liver resection. Thus, the tumor-bearing liver segment can be anatomically removed, which helps to avoid damage to important vessels and reduce ischemia or congestion of the remaining liver tissue. Finally, the incidence of postoperative biliary fistula and liver dysfunction is reduced; therefore, a better prognosis is obtained after the resection of liver cancer. Centrally located liver cancer is usually defined as a tumor located at segments 4, 5, or 8 that requires resection of the middle section of the liver. These are among the most difficult hepatectomies to perform because of the large surgical wounds and multiple vessel transections. Based on the specific tumor location, we formulated the required resection ranges by designing personalized fluorescent staining strategies. By completing anatomical resection based on the portal territory, this work aims to achieve the best therapeutic effect.

The present protocol describes fluorescent negative staining in laparoscopic central hepatectomy. This technique can make hepatectomy more accurate and precise.

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ...

Medicine

Application of Laparoscopic Hepatectomy Combined with Intraoperative Microwave Ablation in Colorectal Cancer Liver Metastasis

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to be maintained during laparoscopic hepatectomy, with a residual liver volume of &gt;40% in cirrhotic patients and &gt;30% in non-cirrhotic patients. The high incidence of complications such as bleeding, bile leakage, or liver failure due to the exposure and difficulty of the resection of specific liver segments such as S2 and S7 reduces the success rate of liver resection. At present, microwave ablation is mainly applied in the treatment of liver metastasis using a percutaneous approach, which makes it difficult to identify hidden parts or small lesions. For some liver segments, the percutaneous puncture of liver segment 7 (S7) is likely to pass through the thoracic cavity, and the percutaneous puncture of liver segment 2 (S2) adjacent to the diaphragm is likely to injure the diaphragm and heart; these issues restrict the application of percutaneous ablation in colorectal cancer liver metastasis. Considering multiple lesions, laparoscopic microwave ablation combined with hepatectomy was performed in this study. The location of the lesions was determined by contrast-enhanced ultrasound under laparoscopy, and small lesions that were difficult to detect before the operation were identified. For the scattered lesions, which had diameters less than 3 cm and were difficult to resect, ablation was adopted to substitute hepatectomy. This technique helped to more explicitly locate the tumors, simplified the operation procedures, reduced the risk of complications such as bleeding and bile leakage, shortened the operation time, accelerated the postoperative recovery, significantly improved the success rate of operation, and enhanced the clinical prognosis of colorectal cancer liver metastasis by surgical resection.

This protocol describes the laparoscopic resection of colorectal cancer liver metastases combined with ultrasound-guided microwave ablation. This technique can safely, effectively, and accurately treat refractory liver metastases &lt;3 cm, reduce postoperative complications, and accelerate the postoperative rehabilitation of patients.

Laparoscopic hepatectomy is a common treatment for colorectal cancer liver metastasis. Previously, a sufficient number of functional liver masses had to ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to the anatomical characteristics of the liver, with intraoperative hemorrhage being a primary concern. Intraoperative blood loss is the leading cause of conversion to open surgery; therefore, effective management of bleeding and hemostasis is crucial for a successful LAH.
The two-surgeon technique is proposed as an alternative to the traditional single-surgeon approach, with potential benefits in reducing intraoperative bleeding during laparoscopic hepatectomy. However, there remains a lack of evidence to determine which mode of the two-surgeon technique yields superior patient outcomes. Besides, to our knowledge, the LAH technique, which involves the use of a cavitron ultrasonic surgical aspirator (CUSA) by the primary surgeon while an ultrasonic dissector by the second surgeon, has been rarely reported before.
Herein, we present a modified, two-surgeon LAH technique, wherein one surgeon employs a CUSA while the other uses an ultrasonic dissector. This technique is combined with a simple extracorporeal Pringle maneuver and low central venous pressure (CVP) approach. In this modified technique, the primary and secondary surgeons utilize a laparoscopic CUSA and an ultrasonic dissectorconcurrently to achieve precise and expeditious hepatectomy. A simple extracorporeal Pringle maneuver, combined with the maintenance of low CVP, is employed to regulate the hepatic inflow and outflow in order to minimize intraoperative bleeding. This approach facilitates the attainment of a dry and clean operative field, which allows for the precise ligation and dissection of blood vessels and bile ducts. The modified LAH procedure is simpler and safer due to its effective control over bleeding as well as the seamless transition between the roles of primary and secondary surgeons. It holds great promise for future clinical applications.

Here, we present a protocol to perform a modified laparoscopic anatomic hepatectomy using improved techniques and instruments.

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to ...

Advancing LRPS: Optimal Techniques for Challenging Liver Resections

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

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.

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.

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver ...

Laparoscopic Sectionectomy Using Ligamentum Teres for Bloodless Hepatectomy

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

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.

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

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 ...

Laparoscopic Left Approach Resection of the Caudate Lobe

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.

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.

Laparoscopic caudate lobectomy (LCL) is one of the most challenging types of laparoscopic liver resections. The main difficulty lies in the deep ...

Peripheral Subtractive Dissection of Glissonean Pedicles in Minimally Invasive Anatomic Liver Resection for Right Posterior Lobe Tumors

Minimally invasive anatomic liver resection (MIALR) has recently garnered significant attention and has rapidly advanced in the field of hepatobiliary surgery. In particular, the dissection of the Glissonean pedicle, such as in Atsushi Sugioka's Gate Theory, represents a fundamental operative technique within MIALR. This technique is based on the anatomical structure of the Laennec capsule, thereby promoting and implementing MIALR in a scientifically rigorous manner. However, potential risks such as hemorrhage, ischemia-reperfusion injury (IRI), and tumor rupture may arise during MIALR in clinical practice, particularly when it is applied to tumors located in the right posterior hepatic lobe near the bifurcation of the Glissonean pedicles (excluding hilar cholangiocarcinoma). To address these challenges, this study introduces a unique surgical approach, termed peripheral subtractive dissection of the Glissonean pedicle (PSDGP), designed to mitigate these potential complications. During the PSDGP procedure in MIALR for liver tumors, the cystic plate approach is utilized to facilitate extrahepatic dissection. Initially, a non-absorbable suture is threaded from Gate VI to Gate IV under the guidance of non-traumatic forceps (or similar instruments). Subsequently, the non-traumatic forceps are passed through Gate V again to retrieve the non-absorbable suture from Gate IV. Finally, both Gate V and Gate VI are used to achieve the separation of the right posterior Glissonean pedicle. This method may improve surgical success rates and yield better oncological outcomes due to its strict adherence to the no-touch and en-bloc principles of tumor resection.

Minimally invasive anatomic liver resection (MIALR) involving Glissonean pedicle ligation for the right posterior hepatic lobe may cause tumor rupture, hemorrhage, and ischemia-reperfusion injury (IRI). This study proposes a novel surgical approach, peripheral subtractive dissection of the Glissonean pedicle (PSDGP), aimed at mitigating these risks.

Minimally invasive anatomic liver resection (MIALR) has recently garnered significant attention and has rapidly advanced in the field of hepatobiliary ...