Left hepatic pedicle control for laparoscopic left lateral segmentectomy

This video demonstrates in detail the primary vascular approach to left lateral segmentectomy, using a 5-port laparoscopic technique. Once the vascular pedicles are well controlled, liver resection is performed with minimal blood loss. Intestinal staplers are used for vascular division while the liver is divided with the ultrasonic (harmonic) scalpel.

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Left hepatic pedicle control for laparoscopic left lateral segmentectomy

Authors

Abstract

This video demonstrates in detail the primary vascular approach to left lateral segmentectomy, using a 5-port laparoscopic technique. Once the vascular pedicles are well controlled, liver resection is performed with minimal blood loss. Intestinal staplers are used for vascular division while the liver is divided with the ultrasonic (harmonic) scalpel.

Type de vidéo

Vidéo chirurgicale

Durée

16'00''

Publication

2007-01

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Jan 2007;7(01).
URL: http://www.websurg.com/doi-vd01en2057.htm

Left hepatic pedicle control for laparoscopic left lateral segmentectomy

1. Adhesiolysis 00'26''

This video demonstrates a left hepatic pedicle control for laparoscopic left lateral segmentectomy. The dissection began by freeing previous adhesions. The liver presented some adhesions to the parietal wall that were also freed. The right liver was not dissected. A laparoscopic liver retractor was introduced and the dissection of the hepatic pedicle started.

2. Porta hepatis dissection and control 01'14''

The first part of the dissection allowed access to the lesser sac. Adhesions between the gallbladder and the duodenum were freed. A fifth port was introduced in the epigastric area in order to place the retractor upwards and allow the exposure of the hepatic pedicle by retracting the liver and the gallbladder. Lymph node removal and dissection of the hepatic pedicle started on its right aspect. A vessel loop was placed around the hepatic pedicle in order to control it in case of sudden hemorrhage.

3. Intraoperative ultrasound 03'21''

Laparoscopic ultrasonography was performed in order to confirm the presence of the single liver metastases located in the segment 3 and to rule out the presence of other metastases.

4. Hilar plate dissection 03'39''

Dissection started using an ultrasonic dissector in order to free some adhesions between segment 3 of the liver and segment 4. This allowed a better access to the hilar plate. Using the ultrasonic dissector, the hepatic pedicle was gradually freed with the aim to isolate the hepatic artery and to remove all the surrounding tissue in order to complete lymph node removal.

5. Hepatic artery dissection 05'13''

This dissection was carried out from the common hepatic artery to its division to the right and left branches. The dissection allowed to clearly identify the origin of the right hepatic artery.

6. Isolation of hepatic artery 06'04''

A vessel loop was placed around the left hepatic artery so that a clamping at its origin could be performed, preserving the vascularization of the right liver during the clamping of the left liver in order to allow an easier dissection of the portal vein.

7. Portal vein dissection 06'37''

The dissection of the main portal vein and its divisions was performed using ultrasonic dissectors as well as blunt dissection. As for the arteries, the objective was to have a complete control of the left portal vein in order to manage it without limiting the vascularization of the right liver. The identification of the right and left branches of the portal vein was completed. The dissection did not allow to clearly isolate the branches dedicated to the segment 4 from the branches dedicated to the left lateral sector because of the inflammation related to the metastases.

8. Isolation of left branch of portal vein 09'01''

Nevertheless, the origin of the left portal branch was clearly identified and controlled with the application of a vessel loop. As the left portal vein and the left hepatic artery were under control, clamping of these 2 vascular branches was achieved.

9. Division of left accessory hepatic artery 09'26''

The dissection was conducted to the lesser sac. A significant left accessory artery originating from the celiac trunk was identified and controlled with clip application.

10. Liver division 09'51''

After complete vascular control of the left liver, the dissection started along the conventional landmarks with ultrasonic dissectors. Five ports were used: - an epigastric port for the liver retractor; - a sub-umbilical port for the camera; - 3 operating ports in which the ultrasonic dissector, a suction device and bipolar graspers were placed. These were successively used to dissect the tissues. The portal pedicle of the left lateral segment was identified. However, some adhesions made its control somehow difficult. The pedicle was dissected on its upper and lower aspects. It was not easy to place an angulated grasper around the pedicle. The dissection was conducted on the lower aspect of the segment. The lymph node resection was completed and the liver capsule was opened along segment 1. This allowed a better dissection of the portal branches of the left lateral segment. Small accessory branches were controlled with the ultrasonic dissector.

11. Intra-hepatic division of segmental portal branch 13'29''

The main portal branch of the left lateral segment was controlled with the application of a GIA stapler using a white cartridge. The GIA application allowed a safe control of the major vessels from the hepatic parenchyma. The dissection was then continued using the same technique. Minor branches were controlled with clip application.

12. Mobilization of segment 2 14'06''

When the dissection came close to the hepatic vein, the upper part of segment 2 was freed from its attachment to the diaphragm.

13. Division of left hepatic vein 14'41''

This allowed to place a suture behind the remnant part of the liver, allowing a very safe dissection of the hepatic vein, controlled as usual with a GIA application.

14. Hemostasis and specimen extraction 14'56''

Hemostasis was completed by the application of a TACOSYL® adhesive which was rolled in a swab, introduced through the 12 mm optical port, and finally applied on the hepatic stump. A 3 minutes compression with a wet swab was performed, allowing an extensive adhesion of this mesh to the liver stump. The surgical procedure was completed by the removal of the operative specimen after its introduction in a retrieval bag.