Video: intrahepatic Glissonian approach for pure laparoscopic right hemihepatectomy.

AIM: To present a video of laparoscopic right hepatectomy using Glissonian technique. A new strategy for liver transection is presented. Liver is divided in three parts. The posterior part, containing short hepatic veins, is divided with stapler before liver transection. Anterior part is fully divided with harmonic scalpel, and the middle part, containing hepatic veins from segments 5 and 8, is the last part to be transected. PATIENT AND METHOD: A 41-year-old woman with right-sided hepatolithiasis and choledocholithiasis was referred for surgical treatment. Patient was positioned in left lateral position. Four trocars were used. Operation began with division of liver ligaments, right liver mobilization, and exposure of the retrohepatic vena cava. Cholecystectomy was performed, followed by intrahepatic access to the right Glissonian pedicle (containing arterial, portal, and bile duct branches of segments 5-8). Two small incisions were performed around hilar plate according to specific anatomic landmarks. A vascular clamp was introduced into those incisions, resulting in ischemic delineation of right liver. Clamp was replaced by a vascular stapler, and stapler was fired. Liver parenchyma was divided by harmonic scalpel combined with vascular stapler. The specimen was extracted through suprapubic incision. Intraoperative cholangiography confirmed a 2-cm common bile duct stone which was immediately removed by endoscopy (endoscopic retrograde cholangiopancreatography, ERCP). Falciform ligament was sutured to maintain the liver in its original anatomical position, avoiding hepatic vein kinking, and abdominal cavity was drained. RESULTS: Operative time was 180 min, with blood loss estimated at 50 ml, without need for transfusion. Postoperative recovery was uneventfully, and patient was discharged on the fourth postoperative day. CONCLUSION: Laparoscopic intrahepatic Glissonian approach is feasible and is a useful technique for rapid and safe control of the right liver pedicle, facilitating laparoscopic right hemihepatectomy. The special strategy described may help laparoscopic surgeons to safely perform this challenging procedure.

Video. One-stage laparoscopic bisegmentectomy 7-8 and bisegmentectomy 2-3 for bilateral colorectal liver metastases.

BACKGROUND: Bisegmentectomy 7-8 is feasible even in the absence of a large inferior right hepatic vein. To our knowledge, this operation has never been performed by laparoscopy. This study was designed to present video of pure laparoscopic bisegmentectomy 7-8 and bisegmentectomy 2-3 in one-stage operation for bilateral liver metastasis. METHODS: A 67-year-old man with metachronous bilobar colorectal liver metastasis was referred for surgical treatment after neoadjuvant chemotherapy. CT scan disclosed two liver metastases: one located between segments 7 and 8 and another one in segment 2. At liver examination, another metastasis was found on segment 3. We decided to perform a bisegmentectomy 7-8 along with bisegmentectomy 2-3 in a single procedure. The operation began with mobilization of the right liver with complete dissection of retrohepatic vena cava. Inferior right hepatic vein was absent. Right hepatic vein was dissected and encircled. Upper part of right liver, containing segment 7 and 8, was marked with cautery. Selective hemi-Pringle maneuver was performed and right hepatic vein was divided with stapler. At this point, liver rotation to the left allowed direct view and access to the superior aspect of the right liver. Liver transection was accomplished with harmonic scalpel and endoscopic stapling device. Bisegmentectomy 2-3 was performed using the intrahepatic Glissonian approach. The specimens were extracted through a suprapubic incision. Liver raw surfaces were reviewed for bleeding and bile leaks. RESULTS: Operative time was 240 minutes with no need for transfusion. Recovery was uneventful. Patient was discharged on the fifth postoperative day. Patient is well with no evidence of disease 14 months after liver resection. Tumor markers are within normal range. CONCLUSIONS: Bisegmentectomy 7-8 may increase resectability rate in patients with bilateral lesions. This operation can be performed safely by laparoscopy. Preservation of segments 5 and 6 permitted simultaneous resection of segments 2 and 3 with adequate liver remnant.

Two-stage laparoscopic liver resection for bilateral colorectal liver metastasis.

BACKGROUND: Hepatectomy may prolong the survival of colorectal cancer patients with liver metastases. Two-stage liver surgery is a valid option for the treatment of bilobar colorectal liver metastasis. This video demonstrates technical aspects of a two-stage pure laparoscopic hepatectomy for bilateral liver metastasis. To the authors' knowledge, this is the first description of a two-stage laparoscopic liver resection in the English literature. METHODS: A 54-year-old man with right colon cancer and synchronous bilobar colorectal liver metastasis underwent laparoscopic right colon resection followed by oxaliplatin-based chemotherapy. The patient then was referred for surgical treatment of liver metastasis. Liver volumetry showed a small left liver remnant. Surgical planning was for a totally laparoscopic two-stage liver resection. The first stage involved laparoscopic resection of segment 3 and ligature of the right portal vein. The postoperative pathology showed high-grade liver steatosis. After 4 weeks, the left liver had regenerated, and volumetry of left liver was 43%. The second stage involved laparoscopic right hepatectomy using the intrahepatic Glissonian approach. Intrahepatic access to the main right Glissonian pedicle was achieved with two small incisions, and an endoscopic vascular stapling device was inserted between these incisions and fired. The line of liver transection was marked following the ischemic area. Liver transection was accomplished with the Harmonic scalpel and an endoscopic stapling device. The specimen was extracted through a suprapubic incision. The falciform ligament was fixed to maintain the left liver in its original anatomic position, avoiding hepatic vein kinking and outflow syndrome. RESULTS: The operative time was 90 min for stage 1 and 240 min for stage 2 of the procedure. The recoveries after the first and second operations were uneventful, and the patient was discharged on postoperative days 2 and 7, respectively. CONCLUSION: Two-stage liver resections can be performed safely using laparoscopy. The intrahepatic Glissonian approach is a useful tool for pedicle control of the right liver, especially after previous dissection of the hilar plate.

Laparoscopic resection of uncinate process of the pancreas.

BACKGROUND: Solid pseudopapillary neoplasm of the pancreas is an uncommon but distinctive pancreatic neoplasm with low metastatic potential [1]. Therefore, whenever feasible, an organ-preserving operation should be performed. As previously reported, women with solid pseudopapillary neoplasm of the pancreas may be best treated by more conservative procedures [2]. Recently, laparoscopic pancreatic resections became more common and are being performed in highly specialized centers. There are only six cases of laparoscopic resection for solid pseudopapillary neoplasm of pancreas published in the English literature and, to our knowledge, laparoscopic resection of uncinate process of the pancreas has never been reported [3-6]. This video demonstrates the technical aspects of a totally laparoscopic resection of the uncinate process of the pancreas in a patient with solid pseudopapillary neoplasm. METHODS: A 26-year-old woman with a 4-cm solid pseudopapillary pancreatic neoplasm was referred for surgical treatment. According to preoperative echoendoscopy, there was a safe margin between neoplasm and main pancreatic duct. The patient was placed in supine position with the surgeon standing between her legs. Four trocars, one 10-mm and three 5-mm, were used. At inspection, the inferior vena cava, transverse colon, duodenum, and pancreas are clearly identified. A Kocher maneuver was performed with complete exposure of pancreatic head and uncinate process. The uncinate process was dissected from the superior mesenteric vein and venous branches were divided between metallic clips or by use of laparoscopic coagulation shears (LCS; Ethicon Endo Surgery Industries, Cincinnati, OH, USA). Blood supply of the duodenum was preserved by ligature of small pancreatic branches from inferior pancreatoduodenal artery. Transection of pancreatic parenchyma was performed using laparoscopic coagulation shears, which is an effective tool for cutting the pancreas [7, 8]. Surgical specimen was removed through a suprapubic incision inside a retrieval bag. A hemostatic absorbable tissue (Surgicel; Ethicon Inc., Cincinnati, OH) was placed in the cutting pancreatic surface, and one round 19F Blake abdominal drain (Ethicon) was left in place. RESULTS: Operative time was 180 minutes and blood loss estimated in 40 ml with no blood transfusion. Hospital stay was 4 days. The patient did not have postoperative pancreatitis or pancreatic leakage, and the abdominal drain was removed on the tenth postoperative day. Final pathology confirmed the diagnosis of solid pseudopapillary neoplasm of pancreas with free surgical margins. The patient was well and asymptomatic 2 months after the procedure. CONCLUSIONS: Laparoscopic resection of uncinate process of the pancreas is safe and feasible and should be considered for patients suffering from pancreatic neoplasms.

Laparoscopic resection of left liver segments using the intrahepatic Glissonian approach.

BACKGROUND: Recent advances in laparoscopic techniques have resulted in growing indications for laparoscopic hepatectomy. However, this procedure has not been widely developed, and anatomic segmental liver resection is not currently performed due to difficulty controlling the segmental Glissonian pedicles laparoscopically. This study aimed to report a novel technique for laparoscopic anatomic resection of left liver segments using the intrahepatic Glissonian approach based on small incisions according to anatomic landmarks such as Arantius' and round ligaments. METHODS: Nine consecutive patients underwent laparoscopic liver resection using the intrahepatic Glissonian technique from April 2007 to June 2008. Five patients underwent laparoscopic bisegmentectomy 2-3, one laparoscopic left hemihepatectomy, two resections of segment 3, and one resection of segment 4. RESULTS: One patient required a blood transfusion. The mean operation time was 180 min (range, 120-300 min), and the median hospital stay was 3 days (range, 1-5 days). No patient had postoperative signs of liver failure or bile leakage. No postoperative mortality was observed. CONCLUSION: The main advantage of the intrahepatic Glissonian procedure over other techniques is the possibility of gaining a rapid and precise access to the left Glissonian sheaths facilitating left hemihepatectomy, bisegmentectomy 2-3, and individual resections of segments 2, 3, and 4. The authors believe that the intrahepatic Glissonian technique facilitates laparoscopic liver resection and may increase the development of segment-based laparoscopic liver resection.

Laparoscopic right hemihepatectomy for hepatolithiasis.

BACKGROUND: Liver resection is the definitive treatment for unilateral hepatolithiasis. Recently, laparoscopic major hepatectomias have become more common and are being performed in highly specialized centers. However, few laparoscopic liver resections for hepatolithiasis have been reported. Chen et al. reported two cases of laparoscopic left lobectomy for hepatolithiasis, but to our knowledge, right hepatectomy has never been reported to date. This video demonstrates technical aspects of a totally laparoscopic right hepatectomy in a patient with hepatolithiasis. METHODS: A 21-year-old woman with right-sided nonoriental primary intrahepatic stones was referred for surgical treatment. The operation followed four distinct phases: liver mobilization, dissection of the right portal vein and right hepatic artery, extrahepatic dissection of the right hepatic vein, and parenchymal transection with harmonic shears and linear staplers for division of segment 5 and 8 branches of the middle hepatic vein. No Pringles' maneuver was used. In contrast to liver resection for other indications, the right bile duct was enlarged and filled with stones. It was divided during parenchymal transection and left open. After removal of the surgical specimen, the biliary tree was flushed with saline until stone clearance, under radioscopic surveillance, was complete. The right hepatic duct then was closed with running suture. RESULTS: The operative time was 240 min, and the estimated blood loss was 120 ml, with no blood transfusion. The hospital stay was 5 days. At this writing, the patient is well and asymptomatic 7 months after the procedure. CONCLUSION: Laparoscopic liver resection is safe and feasible for patients with hepatolithiasis and should be considered for those suffering from intrahepatic stones. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s00464-007-9666-1) contains supplementary material, which is available to authorized users.

Biliary reconstruction without T-tube in liver transplantation.

Biliary complications have been reported in 9% to 34% of liver transplant patients. Although most centers seem to prefer a duct-to-duct anastomosis without a T-tube when feasible, the best method of biliary reconstruction remains controversial. The aim of this study was to review our experience on reconstruction of the biliary tract without drainage. Forty-one patients underwent 45 liver transplants over two periods. Forty patients underwent 15 liver transplants from October 1992 to March 1995; and 27 underwent 30 liver transplants from January 2002 to February 2003. Our standard biliary reconstruction was an end-to-end anastomosis without drain. The overall actuarial survival was 72.7% at 1 year, 64.7% at 3 years, and 56.6% at 5 years. The mean follow-up was 23 months. Eight patients (22.2%) developed biliary tract complications: five patients papillary dysfunction (13.9%); two, biliary stricture (5.5%); and one, biliary sludge without evidence of stricture (2.8%). Papillary dysfunction represented 62.5% of all complications. Biliary reconstruction without drainage may be routinely performed since the complications are only those not related to the T-tube.

Early mortality in liver transplantation: bilirubin as predictor of outcome.

The shortage of donor organs and the long waiting lists have increased the need to better select liver transplant candidates using predictors of success. We reviewed the results of 29 liver transplantations performed from January 2002 to February 2003 analyzing the correlations with early mortality (30 days) of patient data, pretransplant laboratory data, warm ischemia time, intraoperations blood unit transfusions, and postoperative complications of prolonged mechanical ventilation, dialysis, and infection. Overall early mortality was 27.6% and 44% in fulminant hepatic failure (n = 9), there were four retransplants with one death, and two intraoperative deaths. Only pretransplant bilirubin (P =.045) and postoperative lactate levels (P =.002) were significantly different between alive versus dead patients. In this small population bilirubin was more related to death than the MELD score. Lactate levels, nonspecific predictor of death in shock syndromes were probably related to septic complications.

Iliac-hepatic arterial bypass for compromised collateral flow during modified Appleby operation for advanced pancreatic cancer.

Involvement of the celiac trunk and common hepatic artery are two of the most common forms of vascular invasion by tumours of the distal pancreas, and until recently this finding was considered a contra-indication to resection. We described a modified Appleby operation for locally advanced distal pancreatic cancer with compromised hepatic collateral flow that needed hepatic arterial revascularization, successfully accomplished by left external iliac-hepatic arterial bypass with Dacron prosthesis. Patient recovery was uneventful and he was discharged on the 10th postoperative day. Postoperative angio-CT disclosed a patent arterial bypass. Patient is well and asymptomatic 13 months after operation. At the time of this writing, postoperative CT scan showed no evidence of disease and CA 19-9 level is normal. There is a well established rationale to perform extended resection of pancreatic carcinomas that compromise vascular structures. Modified Appleby procedure can safely be performed, has oncological advantages to palliative procedures and provides relief of pain but is reserved for selected patients. Preservation of hepatic arterial flow has utmost importance to avoid hepatobiliary complications as liver necrosis, liver abscess, gallbladder necrosis or cholecystitis. In this case, hepatic revascularization was particularly challenging, but was successfully accomplished by left external iliac--hepatic arterial bypass. To our knowledge this type of arterial bypass has never been described so far in the English literature and its description may be important for surgeons dealing with advanced pancreatic cancer.