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Segment III hepatocellular carcinoma (HCC) and major liver cirrhosis: laparoscopic resection

Laparoscopy for liver resection is a highly specialized surgical field because liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. This video presents the case of a 60-year-old patient presenting with significant liver cirrhosis. During follow-up, a 3cm HCC located in the left liver was diagnosed. CT-scan was reconstructed in order to precisely define the landmarks regarding position of the tumor to the vessels. A laparoscopic approach was decided upon. As expected, a major liver cirrhosis is diagnosed. A parenchyma preserving hepatectomy is performed.

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Segment III hepatocellular carcinoma (HCC) and major liver cirrhosis: laparoscopic resection

Autores

D Mutter, L Soler, J Marescaux

Resumen

Laparoscopy for liver resection is a highly specialized surgical field because liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. This video presents the case of a 60-year-old patient presenting with significant liver cirrhosis. During follow-up, a 3cm HCC located in the left liver was diagnosed. CT-scan was reconstructed in order to precisely define the landmarks regarding position of the tumor to the vessels. A laparoscopic approach was decided upon. As expected, a major liver cirrhosis is diagnosed. A parenchyma preserving hepatectomy is performed.

Clasificación

complex cases

Palabras clave

Segment III hepatocellular carcinoma, HCC, major liver cirrhosis, laparoscopic resection

Tipo de medio

Vídeo quirúrgico

Duración

05'42''

Publicación

2009-07

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Subtítulos

E publicación

WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2659.htm

Segment III hepatocellular carcinoma (HCC) and major liver cirrhosis: laparoscopic resection

1. Clinical case presentation 00'10''

We report the case of a 60-year-old patient presenting with significant liver cirrhosis. During follow-up, a 3cm HCC located in the left liver was diagnosed. CT-scan was reconstructed in order to precisely define the landmarks regarding position of the tumor to the vessels. A laparoscopic approach was decided upon. As expected, a major liver cirrhosis is diagnosed. We decided to perform a parenchyma preserving hepatectomy.

2. Laparoscopic ultrasonography 00'52''

The surgical procedure starts as usual by laparoscopic ultrasonography. A lot of regenerative nodules are identified but no other tumor is identified.

3. Identification of landmarks 01'04''

The landmarks of the tumor are precisely determined by the laparoscopic examination and the landmarks for resection are identified on the liver thanks to monopolar cautery. Resection is performed using 5 ports. One port is used for a 10mm, 30 degree scope. The other ports are used for a liver retractor, 2 instruments for the surgeon, ultrasonic dissector and bipolar cautery, and the assistant is using a liver retractor and a suction drain always following the dissection. These are really the typical tricks that I use to perform a laparoscopic hepatectomy. The suction allows to perform suction of the smoke, ensuring a good quality of vision but also allows to perform immediate suction of any bleeding vessels in order to get an ideal control by the cautery, monopolar or bipolar cautery of these vessels.

4. Hepatic resection 02'15''

Dissection is done progressively at a safe distance of the tumor in order to preserve the parenchyma to avoid injury of the major liver vessels. Most of the little vessels are controlled with the ultrasonic dissector. In case of bleeding, bipolar cautery usually allows to control most of such bleeding. Hepatectomy is performed with a low central venous pressure in order to minimize blood loss during the surgical procedure. In case of difficulty to precisely identify the position of the tumor, added use of virtual reality can be proposed. This allows to precisely identify the position of the tumor and to confirm the resection margin. In case of HCC in this type of patient, we try to keep a margin of 1 to 2cm from the tumor if there is no anatomical resection of a segment. The most difficult parts to dissect are the inferior and posterior parts of the liver. Nevertheless, thanks to the 30 degree angled scope and simultaneous use of bipolar cautery, dissection can be completed without any major problems. Vessels of bigger sizes are controlled using staplers or clips. Vessels of minor sizes are controlled using monopolar or bipolar cautery. Here the use of clips allows to control vessels of 1 to 2mm in size. With this type of liver, bipolar cautery is usually used to perform the completion of hemostasis. Staplers are used for the biggest vessels. Here we can see the control of the hepatic vein of this segment. Hemostasis is completed thanks to bipolar cautery allowing for a deep coagulation into the liver parenchyma. This is known to add some safety margin. After complete mobilization of the operative specimen, the abdomen is cleaned. Bipolar cautery allows a perfect control of the liver’s slice and it has to be noted that no vascular control was performed to preserve the rest of the liver parenchyma. Safety margins of more than 1cm are achieved in this specimen.