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Laparoscopic hepatectomy for a left 8cm hepatocellular carcinoma after embolization for bleeding

This is the case of a patient presenting with a hepatocellular carcinoma, referred to the emergency department because of a hemorrhage. The first step consisted in an arterial embolization. The patient recovers from the embolization and two months later, a left lateral segmentectomy is decided upon. The tumor measures 8cm and is located in segment II and III of the liver. The procedure is performed laparoscopically, away from the digestive bleeding.

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Laparoscopic hepatectomy for a left 8cm hepatocellular carcinoma after embolization for bleeding

Autores

D Mutter, L Soler, J Marescaux

Resumo

This is the case of a patient presenting with a hepatocellular carcinoma, referred to the emergency department because of a hemorrhage. The first step consisted in an arterial embolization. The patient recovers from the embolization and two months later, a left lateral segmentectomy is decided upon. The tumor measures 8cm and is located in segment II and III of the liver. The procedure is performed laparoscopically, away from the digestive bleeding.

Tipo de mídia

Vídeo cirúrgico

Duração

13'07''

Data da publicação

2010-03

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E-publicação

WeBSurg.com, Mar 2010;10(03).
URL: http://www.websurg.com/doi-vd01en2889.htm

Laparoscopic hepatectomy for a left 8cm hepatocellular carcinoma after embolization for bleeding

1. Clinical case presentation 00'10''

This is the case of a patient presenting with a hepatocellular carcinoma referred to the emergency department because of a hemorrhage. The first step consisted in an arterial embolization. The patient recovers from the embolization and two months later, a left lateral segmentectomy is decided upon. The tumor measures 8cm and is located in segment II and III of the liver. Away from the digestive bleeding, the procedure is going to be performed laparoscopically. From the beginning of the procedure, massive omental adhesions covering the whole of the tumor are found.

2. Dissection of the omental adhesions 00'57''

These omental adhesions are progressively taken down using an ultrasonic dissector or a Ligasure® device in turn. This primary exploration helps to rule out the absence of peritoneal carcinosis related to the bleeding and to make sure that the resection is feasible laparoscopically. The bleeding that occurred was responsible for many adhesions, which can be taken down gradually. The anatomical landmarks are also progressively re-identified.

3. Dissection of the tumor\'s superior portion 01'45''

The freeing of the tumor’s superior portion helps to isolate it from the stomach at its inferior pole. The adhesions allow to progressively identify the hepatic hilum again. The liver’s hilum is particularly inflammatory since it is situated in contact to the tumor. Nonetheless, a progressive dissection using either a peanut swab or through the cautery of small vascular structures contributes to the identification of essential anatomical landmarks. The tumor mobilization is uneasy because of the inflammatory adhesions.

4. Dissection of the hepatic pedicle 02'27''

As conventionally, the procedure is begun with the freeing of the hepatic pedicle. Laparoscopically, it is nowadays considered that it is preferable to achieve a primary and selective vascular control of the liver segment to be resected.

5. Dissection of the hepatic artery\'s left branch 02'45''

The left branch of the hepatic artery is dissected and isolated. It is typically placed on a small loop. Dissection within the hepatic pedicle is continued progressively. An extensive dissection of the artery helps to retract it and to identify the portal pedicle at the artery’s posterior aspect.

6. Left portal vein dissection 03'11''

The left portal vein is dissected just above the bifurcation. The right portal vein should be perfectly identified before control of the left branch to rule out any injury. The left branch of the portal vein is then completely isolated. This ensures a vascular hilar control of the liver segment to be resected, preserving the contralateral liver. The vascular elements are not divided in order to preserve the vascularization of segment IV of the liver after surgery. The ischemia will allow for a safe parenchymal dissection of segments II and III of the liver.

7. Start of parenchymal dissection 03'56''

The dissection of the parenchyma may start. First of all, the parenchymal bridge is separated between segment III and segment IV of the liver. The left lateral segment is then resected. Five ports are conventionally used: one port for the camera, one for a liver retractor, one for the suction drain, and the operator works with his two hands successively using the ultrasonic dissector and bipolar cautery to complete the hemostasis in the hepatic parenchyma. The parenchymal dissection is carried out slowly and progressively in order to easily control small bleeders related to both the portal and hepatic pedicles. This dissection also avoids performing an ongoing suction that would turn the laparoscopic approach more painstaking. The objective is to successively identify the vascular pedicles of segments III, then of segment II, and at last to selectively approach the left hepatic vein.

8. Identification of a second tumor in segment IV 05'18''

A daughter tumor is identified at the superior portion of segment IV: it will be resected at the end of the dissection.

9. Pedicle of segment III: dissection and division 05'26''

The first pedicle identified in contact to Rex recess is the portal pedicle heading to segment III of the liver. It is progressively dissected and the accessory vascular structures are controlled with monopolar and bipolar cautery. The first parenchymal and vascular division is performed with a stapler, white cartridge. However, the latter does not allow for a complete control of the vascular pedicle. This dissection is continued slightly to the left and placement of a thread allows to control the entire vascular pedicle heading to segment III of the liver. A new application of a white cartridge staple from right to left allows to control almost the entire portal pedicle. The division is completed after application of an additional clip. Placement of a landmark thread is a safety measure; indeed, it allows to control that the entire pedicle is incorporated within the stapler’s jaws. Since the dissection of the anterior aspect is well advanced, dissection can move on to the diaphragmatic surface.

10. Posterior dissection on diaphragmatic surface 07'01''

The posterior portion of the lobe and of the triangular suspensory ligament are progressively freed. In this case, the ultrasonic dissector is very helpful. However, because of inflammatory adhesions, it is uneasy to identify the junction between the hepatic vein and the vena cava, and a small lateral tear of the vena cava occurs. It is directly sutured using Prolene 4/0. The superior portion of segment III of the liver is totally freed of the diaphragm, dissection may be continued on its anterior surface. The anatomical landmarks have been slightly modified because of the inflammatory adhesions induced by the earlier bleeding. However, these anatomical landmarks are progressively re-identified.

11. Dissection of segment II pedicle 07'51''

The opening of the posterior capsule allows to identify the pedicle of segment II of the liver. Once again, this dissection is carried out meticulously, first on its superior, then inferior portion in order to achieve a perfect control. As for all main pedicles, these are first controlled by passing a wire to ensure that the dissection at the posterior surface is complete. This wire also allows to apply gentle traction during the stapler’s application to ensure that all the large vessel’s borders are in the stapler’s jaws. As before, the stapler comes from the patient’s right so that it can be placed parallel to the hepatic division plane. A parenchymal element remains to be dissected until access to the left hepatic vein. This is a key step of the procedure; the dissection is literally performed millimetre by millimetre, using the ultrasound dissector and bipolar coagulation. Small accessory elements are controlled by applying clips. However, we avoid the use of clips when in contact to the hepatic vein as they could impede the linear stapler’s application. Having dissected the parenchyma above and below the hepatic vein, the Endo-GIA linear stapler can be applied; this will ideally control the hepatic vein’s division. Here again, the stapler’s axis goes from the patient’s right to left to be parallel to the dissection plane and not risk a lateral stapling of the vena cava. The superior angle of the vein that has not been stapled is controlled by clip application and the posterior parenchymal border can be entirely freed.

12. Resection of segment IV tumor 09'54''

The free left segment is shelved in the abdominal cavity and a 1cm daughter tumor situated in the lateral part of liver segment IV will be resected. To do so, the round ligament is preserved, but the liver’s suspensory ligament is opened posterior to the round ligament. This allows access to the superior section of the hepatic dissection plane. This suspicious 1cm nodule is dissected. The vascular control of the hepatic dissection plane allows to perform an intraparenchymal dissection of the liver by a simple application of an ultrasonic dissector. The latter drills the hepatic parenchyma. The preoperative exploration confirmed that this small lesion was away from the main vascular elements. The ultrasonic cautery here allows a perfect control of the small hepatic parenchymal pedicles. The resection of the segments II and III, completed by a small resection of segment IV, is therefore complete. The left hepatic artery and the left branch of the portal vein can be de-clamped. This ensures that there is no hemorrhage in contact to the dissection plane. The vessels are not clipped directly, but only after application of a small elastic loop.

13. Hemostasis of hepatic slice 11'13''

The hemostasis of the hepatic slice can be completed with bipolar cautery if required. All the resected elements are placed in an extraction bag, and are extracted through the enlarged opening of the main trocar following morcellation of the specimen to avoid an excessive enlarging of the opening.

14. TachoSil® placement 11'37''

The hepatic dissection plane is covered by a hemostatic solution. A TachoSil® patch is introduced after having being rolled in a gauze. Its adherent surface is applied to the liver, and the gauze used to introduce the TachoSil® is used to compress and humidify it. The TachoSil®’s aim is to ensure a good quality hemostasis and bile stasis at the hepatic dissection plane’s main section. If required, several patches can be used. A small suction drain is placed systematically to drain any biliary effusion, and this concludes the surgical procedure. The macroscopic examination and the pathological findings confirm the diagnosis of hepatocellular carcinoma, the complete resection and a satisfying safety margin. The drain passes through a trocar site, it will be left in place for 48 hours. The patient is discharged on postoperative day 4.