Laparoscopic Hepatic Left Lateral Sectionectomy

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Author: Iswanto Sucandy
Published:
Specialties: General Surgery
Schools:
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Basic Info

Contributors: David A Geller

Laparoscopic left lateral sectionectomy performed for a 14 cm hypervascular left lobe liver mass which is hypervascular during arterial phase and isodense to liver during venous phasem consistent with giant Focal Nodular Hyperplasia.

DOI: http://dx.doi.org/10.17797/yjare8xwt2

Editor Recruited By: Jeffrey B. Matthews, MD

Advanced

Procedure

LAPAROSCOPIC HEPATIC LEFT LATERAL SECTIONECTOMY
A 34 year old white female patient presents with epigastric pain and elevated liver function tests. She also had early satiety. She has a history of oral contraceptive use for 15 years. On physical examination, a palpable mid-epigastric mass was found. Triphasic liver CT scan shows a 14 cm hypervascular left lobe liver mass, hypervascular during arterial phase and isodense to liver during venous phase. These findings are consistent with giant focal nodular hyperplasia (FNH).

Indications

Significant symptoms (pain/discomfort), mass effects to surrounding structures.

Contraindications

Inability to tolerate general anesthesia and pneumoperitoneum (advanced degree of chronic obstructive pulmonary disease). There are no contraindications to a laparoscopic approach as the patient is young and otherwise healthy.

Instrumentation

Setup

The patient lies supine on the operating table with both arms extended. An orogastric tube is placed for gastric decompression. Operating surgeon stands on the right side of the patient and the assistant on the left. A GelPort® (Applied Medical, Rancho Santa Margarita, CA) is placed via a 5-cm periumbilical midline incision. CO2 pneumoperitoneum is created to a pressure limit of 13. The round and falciform ligaments are ligated and divided. Left upper quadrant 12 and 5-mm ports and a right upper quadrant 12-mm port are placed under direct visualization. The gastrohepatic and left triangular ligaments are taken down. The left hilum is exposed and the inflow structures (hepatic artery and portal vein) are dissected using a right angle clamp. Presence of right hepatic artery flow is confirmed before left hepatic artery division with locking clips. The left lateral portal vein branches are divided with vascular stapler.
The liver parenchymal transection is then performed using a combination of an ultrasonic dissector, endoGIA vascular staplers, and saline-cooled radiofrequency coagulation device. Laparocopic vascular stapler is used to divide larger intrahepatic vessel branches, as well as the left hepatic vein intrahepatically at the end. Hemostasis is confirmed from the liver cut surface and the specimen is retrieved through the handport incision.

Preoperative Workup

Triphasic Liver CT scan or Liver MRI

Anatomy and Landmarks

There are six major steps in laparoscopic hepatic left lateral sectionectomy.
1. Opening of the gastrohepatic ligaments and division of the left triangular ligament.
2. Exposure of the left hilum and inflow dissection
3. Division of the inflow structures
4. Parenchymal transection in a cephalad direction toward the left hepatic vein
5. Intrahepatic division of the left hepatic vein using a vascular stapler
6. Specimen retrieval

Advantages/Disadvantages

Laparoscopic left lateral sectionectomy affords all the benefits of minimally invasive approach for solid organ resection. Less postoperative pain, lower wound complications, less long-term hernia formation, shorter recovery, and improved cosmesis are few among many advantages of this approach, when compared to open hepatectomy. Pneumoperitoneum also decreases blood loss during liver parenchymal transection. Disadvantaged of this operation is related to the mastering the learning curve.

Complications/Risks

Potential intraoperative complications are hemorrhage, major vessel injury (middle hepatic vein and inferior vena cava), and gas embolism. Potential postoperative complications are delayed bleeding, bile leak, and infection.

Disclosure of Conflicts

Potential intraoperative complications are hemorrhage, major vessel injury (middle hepatic vein and inferior vena cava), and gas embolism. Potential postoperative complications are delayed bleeding, bile leak, and infection.

Acknowledgements

None

References

1.Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection ¢ 2,804 patients. Ann Surg. 2009; 250:831¢41.
2.Nguyen KT, Marsh JW, Tsung A, Steel JL, Gamblin TC, Geller DA. Comparative benefits of laparoscopic versus open hepatic resection: a critical appraisal. Arch Surg. 2011; 146:348¢56.
3.Reddy SK, Tsung A, Geller DA. Laparoscopic liver resection. World J Surg. 2011; 35:1478¢86.

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