Name: techniques of laparoscopic right posterior sectionectomy: glissonian approach and a parenchymal transection technique
Uploaded: 2023-10-06T12:10:00
Description: Watch this Scientific Journal Video about Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique at JoVE.com

The study is self-sponsored.

The protocol follows the guidelines of Kwong Wah Hospital&#39;s human research ethics committee.
1. Pre-operative workup
<ol>
	<li>Check triphasic CT scans to evaluate the extent of disease and vascular anatomy.</li>
	<li>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.</li>
	<li>Perform CT volumetry to ensure ade...

Advancing LRPS: Optimal Techniques for Challenging Liver Resections

<ol>
	<li>van der Heijde, N., 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=Laparoscopic+versus+open+right+posterior+sectionectomy:+an+international,+multicenter,+propensity+score-matched+evaluation.">Laparoscopic versus open right posterior sectionectomy: an international, multicenter, propensity score-matched evaluation.</a> Surgical Endoscopy. 35 (11), 6139-6149 (2021).</li><li>Cheng, K. C., Yeung, Y. P., Ho, K. M., Chan, F. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+right+posterior+sectionectomy+for+malignant+lesions:+An+anatomic+approach.">Laparoscopic right posterior sectionectomy for malignant lesions: An anatomic approach.</a> Journal of Laparoendoscopic &amp; Advanced Surgical Techniques. Part A. 25 (8), 646-650 (2015).</li><li>Fretland, A. A., 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=Laparoscopic+versus+open+resection+for+colorectal+liver+metastases:+The+OSLO-COMET+randomized+controlled+trial.">Laparoscopic versus open resection for colorectal liver metastases: The OSLO-COMET randomized controlled trial.</a> Annals of Surgery. 267 (2), 199-207 (2018).</li><li>Landi, F., 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=Short-term+outcomes+of+laparoscopic+vs.+open+liver+resection+for+hepatocellular+adenoma:+a+multicenter+propensity+score+adjustment+analysis+by+the+AFC-HCA-2013+study+group.">Short-term outcomes of laparoscopic vs. open liver resection for hepatocellular adenoma: a multicenter propensity score adjustment analysis by the AFC-HCA-2013 study group.</a> Surgical Endoscopy. 31 (10), 4136-4144 (2017).</li><li>Cho, A., 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=Safe+and+feasible+extrahepatic+Glissonean+access+in+laparoscopic+anatomical+liver+resection.">Safe and feasible extrahepatic Glissonean access in laparoscopic anatomical liver resection.</a> Surgical Endoscopy. 25 (4), 1333-1336 (2011).</li><li>Oztas, M., Lapsekili, E., Fatih Can, M. <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+right+posterior+sectionectomies;+surgical+technique+and+clinical+results+of+a+single+surgeon+experience.">Laparoscopic liver right posterior sectionectomies; surgical technique and clinical results of a single surgeon experience.</a> Turkish Journal of Surgery. 38 (1), 18-24 (2022).</li><li>Siddiqi, N. N., 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=Laparoscopic+right+posterior+sectionectomy+(LRPS):+surgical+techniques+and+clinical+outcomes.">Laparoscopic right posterior sectionectomy (LRPS): surgical techniques and clinical outcomes.</a> Surgical Endoscopy. 32 (5), 2525-2532 (2018).</li><li>Machado, M. A., Makdissi, F. F., Galvao, F. H., Machado, M. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intrahepatic+Glissonian+approach+for+laparoscopic+right+segmental+liver+resections.">Intrahepatic Glissonian approach for laparoscopic right segmental liver resections.</a> The American Journal of Surgery. 196 (4), e38-e42 (2008).</li><li>Machado, M. A., Kalil, A. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Glissonian+approach+for+laparoscopic+mesohepatectomy.">Glissonian approach for laparoscopic mesohepatectomy.</a> Surgical Endoscopy. 25 (6), 2020-2022 (2011).</li><li>Topal, B., Aerts, R., Penninckx, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+intrahepatic+Glissonian+approach+for+right+hepatectomy+is+safe,+simple,+and+reproducible.">Laparoscopic intrahepatic Glissonian approach for right hepatectomy is safe, simple, and reproducible.</a> Surgical Endoscopy. 21 (11), 2111 (2007).</li><li>Park, 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=Safety+and+Risk+factors+of+pure+laparoscopic+living+donor+right+hepatectomy:+Comparison+to+open+technique+in+propensity+score-matched+analysis.">Safety and Risk factors of pure laparoscopic living donor right hepatectomy: Comparison to open technique in propensity score-matched analysis.</a> Transplantation. 103 (10), e308-e316 (2019).</li><li>Yang, Y., 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=Laparoscopic+liver+resection+with+&amp;#34;ultrasonic+scalpel+mimic+CUSA&amp;#34;+technique.">Laparoscopic liver resection with &amp;#34;ultrasonic scalpel mimic CUSA&amp;#34; technique.</a> Surgical Endoscopy. 36 (12), 8927-8934 (2022).</li><li>Kitano, S., Kim, Y. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ICG+clearance+in+assessing+cirrhotic+patients+with+hepatocellular+carcinoma+for+major+hepatic+resection.">ICG clearance in assessing cirrhotic patients with hepatocellular carcinoma for major hepatic resection.</a> HPB Surgery. 10 (3), 182-183 (1997).</li><li>Lim, M. C., Tan, C. H., Cai, J., Zheng, J., Kow, A. W. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=CT+volumetry+of+the+liver:+Where+does+it+stand+in+clinical+practice.">CT volumetry of the liver: Where does it stand in clinical practice.</a> Clinical Radiology. 69 (9), 887-895 (2014).</li><li>Sachdeva, A., Dalton, M., Lees, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Graduated+compression+stockings+for+prevention+of+deep+vein+thrombosis.">Graduated compression stockings for prevention of deep vein thrombosis.</a> Cochrane Database of Systematic Reviews. 11 (11), CD001484 (2018).</li><li>Liu, T. S., 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=Application+of+controlled+low+central+venous+pressure+during+hepatectomy:+A+systematic+review+and+meta-analysis.">Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis.</a> Journal of Clinical Anesthesia. 75, 110467 (2021).</li><li>Ellison, E. C., Zollinger, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Zollinger's Atlas of Surgical Operations. , (2016).</li><li>Kato, Y., 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=Minimally+invasive+anatomic+liver+resection+for+hepatocellular+carcinoma+using+the+extrahepatic+Glissonian+approach:+Surgical+techniques+and+comparison+of+outcomes+with+the+open+approach+and+between+the+laparoscopic+and+robotic+approaches.">Minimally invasive anatomic liver resection for hepatocellular carcinoma using the extrahepatic Glissonian approach: Surgical techniques and comparison of outcomes with the open approach and between the laparoscopic and robotic approaches.</a> Cancers (Basel). 15 (8), 2219 (2023).</li><li>Kamiyama, T., Kakisaka, T., Orimo, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Current+role+of+intraoperative+ultrasonography+in+hepatectomy.">Current role of intraoperative ultrasonography in hepatectomy.</a> Surgery Today. 51 (12), 1887-1896 (2021).</li><li>Huang, J. W., Su, W. L., Wang, S. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Alternative+laparoscopic+intracorporeal+Pringle+maneuver+by+Huang's+loop.">Alternative laparoscopic intracorporeal Pringle maneuver by Huang's loop.</a> World Journal of Surgery. 42 (10), 3312-3315 (2018).</li><li>. Laparoscopes articulating HD 3D videoscope ENDOEYE FLEX 3D (LTF-190-10-3D) Available from: <a target="_blank" href="https://medical.olympusamerica.com/products/laparoscopes/endoeye-flex-3d">https://medical.olympusamerica.com/products/laparoscopes/endoeye-flex-3d</a> (2023)</li><li>Welling, A., Scoggins, P., Cummings, J., Clymer, J., Amaral, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Superior+dissecting+capability+of+a+new+ultrasonic+device+improves+efficiency+and+reduces+adhesion+formation.">Superior dissecting capability of a new ultrasonic device improves efficiency and reduces adhesion formation.</a> Global Surgery. 3 (1), (2017).</li><li>Lortat-Jacob, J. L., Robert, H. G., Henry, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Case+of+right+segmental+hepatectomy.">Case of right segmental hepatectomy.</a> Memoires. Academie de Chirurgie (Paris). 78 (8-9), 244-251 (1952).</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=Glissonean+pedicle+transection+method+for+hepatic+resection:+a+new+concept+of+liver+segmentation.">Glissonean pedicle transection method for hepatic resection: a new concept of liver segmentation.</a> Journal of Hepato-Biliary-Pancreatic Surgery. 5 (3), 286-291 (1998).</li><li>Ramacciato, 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=Effective+vascular+endostapler+techniques+in+hepatic+resection.">Effective vascular endostapler techniques in hepatic resection.</a> International Surgery. 83 (4), 317-323 (1998).</li><li>Figueras, 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=Hilar+dissection+versus+the+&amp;#34;glissonean&amp;#34;+approach+and+stapling+of+the+pedicle+for+major+hepatectomies:+a+prospective,+randomized+trial.">Hilar dissection versus the &amp;#34;glissonean&amp;#34; approach and stapling of the pedicle for major hepatectomies: a prospective, randomized trial.</a> Annals of Surgery. 238 (1), 111-119 (2003).</li><li>Jegadeesan, M., Jegadeesan, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anatomical+basis+of+approaches+to+liver+resection.">Anatomical basis of approaches to liver resection.</a> Acta Scientific Gastrointestinal Disorders. 3 (12), 17-23 (2020).</li><li>Eikermann, M., 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=Prevention+and+treatment+of+bile+duct+injuries+during+laparoscopic+cholecystectomy:+the+clinical+practice+guidelines+of+the+European+Association+for+Endoscopic+Surgery+(EAES).">Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES).</a> Surgical Endoscopy. 26 (11), 3003-3039 (2012).</li><li>Imamura, 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=Prognostic+significance+of+anatomical+resection+and+des-gamma-carboxy+prothrombin+in+patients+with+hepatocellular+carcinoma.">Prognostic significance of anatomical resection and des-gamma-carboxy prothrombin in patients with hepatocellular carcinoma.</a> British Journal of Surgery. 86 (8), 1032-1038 (1999).</li><li>Lee, N., 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=Application+of+temporary+inflow+control+of+the+Glissonean+pedicle+method+provides+a+safe+and+easy+technique+for+totally+laparoscopic+hemihepatectomy+by+Glissonean+approach.">Application of temporary inflow control of the Glissonean pedicle method provides a safe and easy technique for totally laparoscopic hemihepatectomy by Glissonean approach.</a> Annals of Surgical Treatment and Research. 92 (5), 383-386 (2017).</li><li>Otsuka, Y., 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=What+is+the+best+technique+in+parenchymal+transection+in+laparoscopic+liver+resection?+Comprehensive+review+for+the+clinical+question+on+the+2nd+International+Consensus+Conference+on+Laparoscopic+Liver+Resection.">What is the best technique in parenchymal transection in laparoscopic liver resection? 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The critical components of the surgery include the intrahepatic Glissonian approach for inflow control, a &#39;ultrasonic scalpel mimic CUSA&#39; 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<sup class...

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 outcomes1,2,3,4. 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 feasibility2,5,6,7. 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 &#39;ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)&#39; 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 approach8,9,10. 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 &#39;ultrasonic scalpel mimic CUSA&#39; technique in 201911, which has been shown to reduce intraoperative blood loss and operative time11,12.
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).&#160;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&#39;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.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>3D ENDOEYE Flex</td>
			<td>Olympus&#160;</td>
			<td>LTF-S190-10-3D</td>
			<td>Flexible tip laparoscopic camera</td>
		</tr>
		<tr>
			<td>5 mm ROBI Bipolar Grasping Forceps</td>
			<td>KARL STORZ</td>
			<td>38851 ON</td>
			<td>atraumatic, fenestrated forceps</td>
		</tr>
		<tr>
			<td>AESCULAP Challenger Ti-P</td>
			<td>Barun</td>
			<td>PL520L</td>
			<td>Pneumatic driven multi-fire clip applicator. 5 mm metal clips</td>
		</tr>
		<tr>
			<td>Endo GIA Reloads with Tri-Staple Technology, 30 mm, Tan colour</td>
			<td>Medtronic&#160;</td>
			<td>SIG30AVM</td>
			<td>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.</td>
		</tr>
		<tr>
			<td>Endo GIA Ultra Universal Stapler</td>
			<td>Medtronic&#160;</td>
			<td>EGIAUSTND</td>
			<td>Manual stapler that compresses tissue while it simultaneously lays down a staple line and transects the tissue</td>
		</tr>
		<tr>
			<td>HARMONIC ACE+7 Shears</td>
			<td>Ethicon</td>
			<td>HARH36</td>
			<td>Curved tip, energy sealing and dissecting, diameter 5 mm, length 36 cm</td>
		</tr>
		<tr>
			<td>Hem-o-lok Clips L</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544240</td>
			<td>Vascular clip 5&#8211;13 mm Size Range</td>
		</tr>
		<tr>
			<td>Hem-o-lok Clips ML</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544230</td>
			<td>Vascular clip 3&#8211;10 mm Size Range</td>
		</tr>
		<tr>
			<td>Hem-o-Lok Polymer Ligation System</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544965</td>
			<td></td>
		</tr>
		<tr>
			<td>Profocus 2202 Ultraview 800</td>
			<td>BK Medical&#160;</td>
			<td>N/A</td>
			<td>Intraoperative Ultrasonography</td>
		</tr>
	</tbody>
</table>

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.

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...

Watch this Scientific Journal Video about Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique at JoVE.com

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

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 ...

After inserting the laparoscope ports in the patient, complete the division of the triangular ligament until the bare area of the liver is exposed. Expose the groove that lies between the right hepatic veins and the common trunk of the middle and left hepatic veins. Then, incise the inferior peritoneal attachment and gently lower the adrenal gland to the retroperitoneum.Divide the short hepatic veins and the ligament connecting to the vena cava until the inferior border of the right hepatic vein becomes visible. Carefully dissect along the superior border of the right posterior Glissonean pedicle along the Rouviere's sulcus, while ensuring the integrity of the Laennec capsule. Then transect the caudate process to reveal the inferior margin of the right posterior Glissonean pedicle.Dissect along the inferior border of the right posterior Glissonean pedicle along the Rouviere's sulcus. Using a bulldog clamp, control the right posterior pedicle. With the help of an ultrasonic scalpel, carefully open the liver capsule.Make the incision at the dome of the liver, precisely along the left margin of the right hepatic vein, ensuring a secure and accurate transection plane. Then use diathermy to mark the remainder of the transection line along the ischemic line. Using Huang's loop and a shortened Foley catheter, prepare an intracorporeal tourniquet for the laparoscopic Pringle maneuver.Carefully open the liver capsule along the predetermined transection line. Heat both arms of the ultrasonic scalpel in the open position. Utilize the active blade of the ultrasonic scalpel for tissue dissection.Activate the ultrasonic scalpel at its maximum power setting, and move the active blade in a horizontal swinging motion parallel to the vasculobiliary structures. Then dissect the liver parenchyma while exposing individual intrahepatic vessels and ensuring their preservation. Employ a suction device with the left hand to maintain a dry surgical field continually.And then use either plastic clips or metal clips to divide large vessels or pedicle structures. Use an ultrasonic scalpel to divide small vessels. To address bleeding, use bipolar diathermy while simultaneously using suction to maintain a clear surgical field.Wrap vascular tape around the right posterior pedicle before cutting with a vascular stapler. Use intracorporeal sutures for significant bleeding, such as bleeding from the right hepatic vein. Transect the right hepatic vein using a vascular stapler.Finally, place the specimen into a plastic bag and retrieve the specimen through the Pfannenstiel incision. In the representative case, the total operative time was 738 minutes, with an estimated blood loss of 400 milliliters. The patient was discharged on post-operative day five.The resection margin was 14 millimeters.

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Laparoscopic pancreatoduodenectomy (LPD) is a standard radical operation for pancreatic head malignant tumors by now. Due to the complex laparoscopic ...

Arthroscopic Double Posteromedial Approach for PCL Cyst Excision

Arthroscopic Excision of Posterior Cruciate Ligament Cysts Using a Double Posteromedial Approach

Author Spotlight: Double Posteromedial Approach for Treating Posterior Cruciate Ligament Cysts

Cruciate ligament cysts of the knee are a rare condition. Posterior cruciate ligament cysts of the knee are less common than anterior cruciate ligament ...

Laparoscopic Posterior Radical Antegrade Modular Pancreatosplenectomy for Distal Pancreatic Carcinoma

Distal pancreatic carcinoma is a highly malignant tumor with strong invasiveness, often growing to the edge of the pancreas and penetrating the pancreatic ...