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Laparoscopic left lateral segmentectomy for hepatocellular carcinoma in cirrhosis: primary vascular approach

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Laparoscopic left lateral segmentectomy for hepatocellular carcinoma in cirrhosis: primary vascular approach

作者群

D Mutter, B Dallemagne, J Marescaux

媒體類型

手術影片

期間

15'30''

刊物

2006-03

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最愛

Favorites Media

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數位出版

WeBSurg.com, Mar 2006;6(03).
URL: http://www.websurg.com/doi-vd01en1922.htm

Laparoscopic left lateral segmentectomy for hepatocellular carcinoma in cirrhosis: primary vascular approach

1. Pneumoperitoneum 00'14''

This is the case of a 67-year-old with a hepatocellular carcinoma of 2.5cm situated at the junctions of segments 2 and 3 of the liver. A transplantation is contraindicated due to previous head and neck cancer. The operation is performed with the patient in supine position with the legs apart, the so-called “French position”. The surgeon is between the legs and the pneumoperitoneum is established by an open technique. Exploration of the peritoneal cavity is performed in order to ensure the absence of carcinomatosis. Retraction of the liver shows the position of the tumor.

2. Intraoperative ultrasound scanning 01'16''

The intervention is started with intraoperative ultrasound scanning. This is not to confirm the position of the tumor but to ensure that there is not a second lesion and in order to ensure that the distribution of vascularity is as preoperatively predicted. We have decided to do a primary vascular approach in order to excise segments 2 and 3. A tape is placed around the falciform ligament in order to improve retraction. This then lifts up the lower border of the liver so that the hepatic pedicle can be approached. We use 5 trocars and the dissection is essentially performed using ultracision and the liver is retracted using an atraumatic retractor, the Endoflex. As for all hepatic procedures, the first thing is to ensure vascular control. Therefore, a tape is placed behind the hepatic pedicle after liberation of some adhesions around the gallbladder.

3. Vascular control of hepatic pedicle 03'15''

Here we can see the tape being placed behind the hepatic pedicle. It will then be secured with clips and be available should quick hepatic control be required. The next stage is dissection of the hepatic pedicle in order to ensure that the vascular control can be performed prior to any further dissection. This is with particular reference to the arteries and veins for segments 2 and 3. The dissection starts with the liberation of the left hepatic artery. This is done in order to ensure that this can be controlled should any hemorrhage occur. The dissection of the structures in the porta continues and at the same time we are able to divide any fatty peritoneal tissue and also to retrieve lymph nodes from this area.

4. Portal vein dissection 05'11''

The portal vein is then isolated and this would also be controlled in order to ensure that should there be any hemorrhage a quick vascular control is possible. This is performed using a right angle with gentle dissection and then the passing behind of another tape which is once again secured in place with clips. The dissection then continues into the hilum of the liver. The plan is to successively find the branches of the division of the left hepatic artery and then to identify the branches of the division of the left portal vein. Dissection of the left hepatic artery permits the identification of the branches which are going to segments 2 and 3 and also those which go to segment 4. The left hepatic artery is retracted over to the right in order to improve the exhibition of the venous portal system. Behind the hepatic pedicle, we can identify the bifurcation of the portal vein. This dissection is imperative in order to ensure that the branches of the portal vein which are going to the left are identified. Once the 2 branches of the portal vein, right and left, are perfectly identified, we can then continue with the dissection.

5. 3D reconstruction of liver 08'20''

The 3D reconstruction confirms the distribution of the vascular structures in the hilum of the liver. The vascular elements specifically for segments 2 and 3 are seen on the reconstruction as are those for segments 4B. These have been exposed in a precise fashion. The next objective is to isolate the specific elements that are destined for segment 4 versus those vascular elements which are destined for segments 2 and 3. This approach allows us to respect the principles of a “no touch” technique in order to dissect and resect the tumor. Once these vascular structures have been identified, we can then proceed to clipping the branches. We can see now that there has been a definitive colour change in the liver. That colour change associated with segment 4 is properly due to an accessory branch going to segment 4 that was divided.

6. Liver resection 10'45''

We can now start the liver resection. This is essentially done using the ultrasound technique and also with bipolar. We make sure that at all times there is suction present in case there is significant hemorrhage. There is no specific technique to be utilized here because we should be in a bloodless plane due to the vascular control we have achieved previously. Any small vessels that are encountered are controlled with clips and coagulation. The large vessels that are found, we pass a tie behind them. This helps with retraction and then they can be brought forward into the jaws of a vascular stapler. We use a white cartridge, these are vascular staples and the stapler must be placed entirely across the venous structure. Dissection continues slowly using the ultracision and the bipolar diathermy. Vessels must be identified and controlled as you come across them. The portal pedicle for segments 2 and 3 is now identified and this will also be divided using the vascular stapler.

7. Division of left hepatic vein 13'33''

We now see the left hepatic vein. The 3D reconstruction shows how it is passing into the liver parenchyma here and we divide it using the vascular stapler again. The resection is now completed. The next stage is to ensure hemostasis. This is done using bipolar diathermy. The tape is then withdrawn from around the portal structures.

8. Extraction of specimen 14'26''

A bag is now being introduced into the peritoneal cavity. We retrieve a swab that we’ve used and the next stage is to place the specimen into the bag. This is in order to ensure that there is no dissemination of cancer cells. It is then withdrawn through a 4cm incision in the abdominal wall. A drain is placed for security and the segment that has been resected measures 12cm and we can see here the 3D reconstruction of it. This is superimposed to show the position of the tumor and the vascular structures that we have dissected. The specimen is then opened in order to ensure that here is a good margin around it. The patient went home on day 5.