Maneuvers Common to All Laparoscopic Liver Surgery

As with open surgery, laparoscopic surgery starts with mobilization of the liver (Fig. 4.3). This is the key to successful surgery as it clears the area surrounding the lesion allowing direct access. This procedure is familiar to all hepatic surgeons.

The first step is division and ligation of the round and falciform ligaments between clips, with a vascular stapler, or with the harmonic shears so that the anterosuperior surface of the liver can be pushed down. Retraction of the liver is achieved with a fan retractor held by an assistant, while the surgeon brings the harmonic shears above the liver and divides the triangular ligament under direct view. The left triangular ligament is divided if the lesion is on the left lobe, or partial division of the right triangular ligament (which is more difficult) for a right posterior lesion. During a major resection, such as a left lateral segmentectomy, it is necessary to be able to approach the side of the superior vena cava to control the hepatic veins, in particular the left hepatic vein. Once the liver is completely mobilized an incision is made in Glisson’s capsule, using the harmonic shears (Fig. 4.4).

Next, long Kelly forceps simulate the finger fracture method. An ultrasonic dissector is very handy here, enabling parenchymal destruction while preserving the vascular and ductal elements.All large vascular vessels must be controlled by clips or by ties in the case of a major vessel or biliary duct.Vascular endolinear cutters are extremely useful for controlling large vessels.

At the end of the operation, the liver segment must be placed in a suitable retrieval bag that allows extraction without spillage of liver cells. Extraction is usually accomplished by enlarging the umbilical opening. Other extraction sites are possible; for larger specimens, a suprapubic incision can be used, or in the case of hand-assisted techniques, the extraction site is the same as the incision used for the introduction of the gelport and the nondominant hand (depicted here on the right side of the patient, Fig. 4.5). The

Fig. 4.3  Mobilization of the liver. A faliciform ligament; B left triangular ligament; C right trian-

gular ligament

Maneuvers Common to All Laparoscopic Liver Surgery

This is a relatively easy procedure; for single giant cysts, the basic trocar approach is used (Fig. 4.1a, b). The harmonic shears are used to fenestrate the cyst after incising its most protuberant area. Each leaf of the cyst is elevated with the grasper, and the cyst is excised at its junction with normal hepatic parenchyma (Fig. 4.7). Clips should be placed to ensure hemostasis, as the number one postoperative problem is bleeding from the liver edge. If the cyst is very large with a thick membrane, a linear cutter with vascular loads can be used to achieve this resection at the liver edge. In the case of polycystic liver disease, the operation proceeds with the same technique through previously unroofed cysts; however, when dealing with deeper cysts, care should be exercised to avoid injury to a hepatic vein or pedicle, as these vascular structures have a similar appearance as that of liver cysts under the illumination of the laparoscope (transparent with a bluish tinge).

Fenestration of Liver Cysts

(Fig. 4.6)

Enucleation, wedge resection, anterior segmentectomies, and left lateral segmentectomies are reasonable laparoscopic technical possibilities. Lobectomies are very advanced procedures reserved for a few laparoscopic liver experts (Fig. 4.8).

Resection of

Liver Tumors