Name: application of the en bloc concept combined with anatomic resection in laparoscopic hepatectomy
Uploaded: 2023-03-10T15:00:00
Description: Watch this Scientific Journal Video about Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy at JoVE.com

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., 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. 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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>

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