D

E

A

C

B

Basic resections

Advanced resections

Very complex resections

Fig. 4.8   Different  levels  of  complexity  based  on  learning  curve.  A  enucleation;  B atypical  peripheral wedge; C segmentectomy; E left lateral sectoriectomy; D lobectomy

Limited Resection of Minor Lesions

Wedge resection of a solid benign tumor, such as an adenoma, is a good example of a small lesion that can be removed laparoscopically.A small metastasis in the left lobe also can be safely resected under laparoscopy with a reasonable 15–20 mm surgical margin. Four trocars are necessary for access: an umbilical trocar for the laparoscope, two large trocars for the grasping forceps and other instruments, and one sub-xiphoid trocar for the irrigation/aspiration probe. For a larger resection it is necessary to use the “fourhanded approach” described above (Fig. 4.2a, b).

The resection begins with incision of Glisson’s capsule 2 cm from the lesion. Smoke must be sucked out intermittently through the irrigation/aspiration cannula. It is then necessary to dissect progressively deeper into the hepatic parenchyma using the harmonic shears while separating the edges of the liver with the left handed forceps. Sometimes a fifth trocar is needed for the assistant to insert a grasper to carefully move the tumor mass. This will create a groove through which a hook or coagulating scissors can pass. Atraumatic grasping forceps allow the minute structures to be coagulated as they pass through this groove. All bile ducts should be clipped or tied; it is not recommended to rely on the harmonic shears to seal bile ducts, as this can lead to postoperative bile leaks. Clips must be employed for larger vessels, and it is recommended that a double clipping technique be used to avoid inadvertent dislocation of a single clip on a vascular pedicle. The irrigation/ aspiration probe should be used in a deep groove in the liver to keep the operating field dry. The need to maintain a bloodless field by means of constant rinsing of the dissection area cannot be overemphasized. With a small wedge resection drainage is not usually necessary.

58 Chapter 4 Laparoscopic Liver Surgery

When dealing with large liver masses, the author routinely performs cholangiography at the conclusion of the resection, to identify possible biliary leaks. This, of course, cannot be done without cholecystectomy. A 5–8 cm solid tumor can be extracted in a bag without difficulty by enlarging the fascial incision at the umbilicus so that the extracted specimen is left intact.The specimen should always be removed in a tumor-proof solid bag.

Left Lateral Segmentectomy

This approach is aimed at larger tumors on the left lobe for which a wedge resection or limited segmentectomy may prove to be incomplete and therefore inadequate treatment. Larger lesions of the left lobe may also be best dealt with by a formal resection when a wedge procedure might actually prove to be more difficult and hazardous. Laparoscopic left lateral segmentectomy, however, should only be considered by surgeons who have extensive experience in both laparoscopy and liver surgery.

Placement of the ports is as shown in Fig. 4.2a, b. This allows for simultaneous maneuvers by two surgeons operating in harmony (four hands approach) - one doing the dissection and the other concentrating on hemostatic control and the clipping of all vessels. The lead surgeon usually operates the ultrasonic dissector while the second surgeon applies clips and divides the isolated vessels. This technique speeds the procedure and enhances safety.

The procedure follows the same rules as in open surgery. It begins with extremely careful hepatic vascular isolation. This includes the left hepatic vein which must be isolated before the liver capsule is incised. The falciform ligament is divided until the vena cava is seen.

A Pringle maneuver can then he performed using an atraumatic right-angled dissector, and a tourniquet is placed around the porta hepatis (Fig. 4.9a, b). Then, after full mobilization of the left triangular ligament, it is possible to retract the left lobe inferiorly using an atraumatic fan retractor allowing one to see the insertion of the left hepatic vein on the vena cava. This is an extremely dangerous maneuver and should be done only by a very skilled laparoscopic surgeon.

Now a right-angled atraumatic dissector is introduced and the left hepatic vein is encircled using gentle blunt dissection and a long tie placed around it. An atraumatic clamp should always be kept handy in the vicinity in case there is bleeding that requires immediate compression and clamping. However, a bleeding left hepatic vein is a dramatic event. Therefore, unless this vessel is safely controlled within seconds of hemorrhaging, the surgeon should opt for an immediate safe conversion. If the left hepatic vein has a short course outside the liver parenchyma before joining the inferior vena cava, dissection should not be attempted. The vein will be controlled during parenchymal dissection.

After incision of the capsule, dissection is continued into the deep parenchyma. During parenchymal dissection one encounters the constituents of the portal pedicle. They are ideally controlled with clips, and reinforced by intracorporeal ligatures when necessary. Intracorporeal knotting will avoid traction on the vessel. That said, it is easier to try to secure all vascular elements with clips, as it is difficult to apply sutures laparoscopically in the liver as the tissue is very friable.

Fig. 4.10  Left  lateral  segmentectomy  with  intrahepatic  division  of  the  left  hepatic  vein.  A division of left triangular ligament; B extrahepatic ligation of left hepatic vein; C control of  vascular pedicles of segments II and III; D division of left hepatic vein

The last vessel to be encountered is the left hepatic vein that has been isolated previously. It is transected using a vascular stapler (Fig. 4.10).

In general, the lobectomy specimen is then placed in an extraction bag and can be withdrawn only if it undergoes some degree of morcelation. The hepatic surfaces are inspected and hemostasis is completed. Here again, cholangiographic examination to detect bile leaks is useful. The application of fibrin sealant when possible is invaluable. The greater omentum can be used to cover the raw surface of the liver at the end of the procedure.After left lateral segmentectomy, the procedure concludes with the placement of two suction drains near the edge of the wound to collect any minor persistent oozing of blood or bile and to prevent hematomas.

Smaller resections such as limited segmentectomies are done in the same way, with the same concern for hemostasis and control of the biliary ducts. One good method is to use vascular staplers for these minor liver resections. Vascular white staples can easily control the hemostasis of small pedicles but it is advisable to start the resection by scarring the capsule with a hook. Once the parenchyma is penetrated, the vascular stapler can then be applied.