Dorsal Approach Combined with In Situ Split for Laparoscopic Segment 7 Resection.

BACKGROUND: Laparoscopic segment 7 resection has been a technically challenging procedure (Li et al. in J Gastrointest Surg 23:1084-1085, 2019). We introduce a dorsal approach with in situ split for laparoscopic segment 7 resection. PATIENT AND METHODS: The patient was a 26-year-old male diagnosed with hepatic focal nodular hyperplasia located in segment 7. The lesion, measuring approximately 6.7 cm × 5.7 cm, was close to the right caudate lobe. Firstly, the segment 7 pedicle was exposed through the Rouviere's groove combined with caudate lobe-first approach, followed by clipping to confirm demarcation. Peripheral parenchymal transection at the dorsal side started and the intersegmental vein between segments 6 and 7 was found. Dissection of this vein towards its root proceeded preferentially at the dorsal side. Then the segment 7 pedicle was cut off, followed by parenchymal transection toward the cranial side to find the trunk of the compressed right hepatic vein (RHV). It was further dissociated from the trunk to periphery, exposing and cutting off its branches draining segment 7. The remaining parenchyma at the cranioventral side was subsequently separated along the exposed RHV. Finally, the resection of segment 7 was accomplished by dividing the right perihepatic ligaments. RESULTS: The operative time was 395 min with the estimated blood loss of 500 ml. The patient did not receive perioperative blood transfusion. The patient was discharged on tenth postoperative day following suture removal without experiencing any postoperative bleeding, hepatic failure, or other complications. CONCLUSION: Dorsal approach combined with in situ split for laparoscopic segment 7 resection is feasible and has certain advantages (Cao et al. in Surg Endosc 35:174-181, 2021; Liu et al. in Surg Oncol 38:101575, 2021; Yang et al. in Surg Endosc 37:1334-1341, 2023). Further investigations are required due to some limitations.

Clinical impact and role of major vessels involvement in laparoscopic resection for hepatic hemangioma.

BACKGROUND: Severe bleeding remains a significant concern in laparoscopic resection for hepatic hemangioma. It is rarely reported that how the degree of major vessels involvement impacts on severe bleeding. The present study primarily aimed to analyze the impacts of the number of involved major vessels (NIMV) during laparoscopic surgery for hepatic hemangioma and evaluate the risk factors associated with increased bleeding. METHODS: A database search was carried out for consecutive patients who underwent laparoscopic resection for liver hemangiomas at our department from January 2018 to December 2023. The collected data included demographics, characteristics of the hemangiomas, laboratory data, operation method, surgical and postoperative variables. RESULTS: A total of 72 patients were enrolled in the study. 42 patients were categorized into the group with NIMV < 2, while 30 patients were divided into the group with NIMV ≥ 2. The group with NIMV ≥ 2 demonstrated a significant correlation with special segments, involved multiple segments and diameter of the hemangiomas (P < 0.01). And the perioperative variables including the extent of resection, operative time, blood loss, Pringle maneuver times, postoperative stay, drainage tube duration, and postoperative liver function (ALT, AST) also showed significant differences between the two groups (P < 0.05). Notably, NIMV ≥ 2 was identified as the most important independent risk factor for intraoperative blood loss ≥ 500 ml in laparoscopic surgery for hepatic hemangioma (P = 0.011). For NIMV ≥ 2, the independent risk factor was special segments in multivariate analysis (P = 0.000). CONCLUSION: The involvement of multiple major vessels (NIMV ≥ 2) was significantly associated with special segments, resulting in increased intraoperative blood loss, operation difficulty, and delayed postoperative recovery. Moreover, it was identified as the single independent risk factor with a considerable risk for increased blood loss during laparoscopic resection for hepatic hemangioma.

Caudodorsal approach combined with in situ split for laparoscopic right posterior sectionectomy.

BACKGROUND: Laparoscopic right posterior sectionectomy (LRPS) was technically challenging and lack of standardization. There were some approaches for LRPS, such as caudal approach and dorsal approach. During our practice, we initiated pure LRPS using the caudodorsal approach with in situ split and present several advantages of this method. METHODS: From April 2018 to December 2021, consecutive patients who underwent pure LRPS using the caudodorsal approach with in situ split at our institution entered into this retrospective study. The key point of the caudodorsal approach was that the right hepatic vein was exposed from peripheral branches toward the root and the parenchyma was transected from the dorsal side to ventral side. Specially, the right perihepatic ligaments were not divided to keep the right liver in situ before parenchymal dissection for each case. RESULTS: 11 patients underwent pure LRPS using the caudodorsal approach with in situ split. There were 9 hepatocellular carcinoma, 1 sarcomatoid hepatocellular carcinoma, and 1 hepatic hemangioma. Five patients had mild cirrhosis and 1 had moderate cirrhosis. All the procedures were successfully completed laparoscopically. The median operative time was 375 min (range of 290-505 min) and the median blood loss was 300 ml (range of 100-1000 ml). Five patients received perioperative blood transfusion, of which 1 patient received autologous blood transfusion and 2 patients received blood transfusion due to preoperative moderate anemia. No procedure was converted to open surgery. Two patients who suffered from postoperative complications, improved after conservative treatments. The median postoperative stay was 11 days (range of 7-25 days). No postoperative bleeding, hepatic failure, and mortality occurred. CONCLUSION: The preliminary clinical effect of the caudodorsal approach with in situ split for LRPS was satisfactory. Our method was feasible and expected to provide ideas for the standardization of LRPS. Further researches are required due to some limitations of this study.

Effects of retrograde reperfusion on the intraoperative internal environment and hemodynamics in classic orthotopic liver transplantation.

BACKGROUND: To investigate the effects of retrograde reperfusion on the intraoperative internal environment and hemodynamics in classic orthotopic liver transplantation (OLT). METHODS: Thirty patients were undergone classic OLT using retrograde reperfusion in our center. Blood sampling was done at different time points including: Before blood venting via the portal vein (PV), 10 mL of blood was collected from the inferior vena cava (T0); During retrograde reperfusion through the inferior vena cava (IVC), 10 mL of blood was collected when the volume of blood venting reached 10 mL (T1), 100 mL (T2), and 200 mL (T3), respectively. 5 mL of blood was analyzed using a NOVA-f-type Blood Gas Analyzer. The remaining 5 mL was measured to determine the level of IL-1ß using an enzyme-linked immunosobent assay. RESULTS: All operations were completed successfully, and postreperfusion syndrome (PRS) occurred in 6 patients (20%). The most notable findings were significant changes at T1, T2 and T3, including pH value, PvO2, SvO2, BEecf, HCO3-, Lac, K+, Ca2+ and IL-1ß, compared with T0 (P < 0.05). Yet their levels at T3 were not back to the level at T0 (P < 0.05). CONCLUSION: This retrograde perfusion could eliminate some harmful metabolites inside the donor liver in time and reduce acid-base and electrolyte disorders as well as drastic hemodynamic fluctuations after recirculation during classic OLT.