Laparoscopic liver resection for cancer

  • Abstract
    This video demonstrates a left hepatic lobectomy of segments 2 and 3 in a patient with a large secondary lesion from a colon cancer. The video demonstrates the access to the vascular pedicles of segments 2 and 3 before division using a stapler. The liver parenchymal division was done with CUSA. The left hepatic vein was divided last after full mobilization of the lobes. The cut surface of the liver was sealed with Argon laser and sealant glue.
  • 00'08" Case report
    Demonstrated in this video is a laparoscopic left lobectomy. A preoperative CT-scan illustrates a 16cm tumor situated in Couinauds’s segments 2 and 3.
  • 00'29" Start of procedure
    The falciform ligament is retracted towards the right and the resection commenced with division of the tissue between segments 3 and 4. The bulky tumor is seen extending from the inferior surface of segment 3. The falciform ligament is followed into the umbilical fissure and the superficial tissues divided to expose the inferior aspect of the segment 3 pedicle. The surface of the liver is marked with diathermy along the transection line to the left of the falciform ligament. The liver parenchyma is divided using the radiofrequency dissection hook and the hepatotomy deepened to the level of the segment 3 pedicle. The surface of the liver is scored with diathermy along the full resection line and the liver capsule divided with cutting diathermy. The left lobe is fully mobilized by dividing the left triangular ligament. Care is taken to avoid the left phrenic vein joining the left hepatic vein. The left hepatic vein may lie very superficially on the superior aspect of the left lobe, and this can be exposed by simple division of the peritoneum. No effort is made to isolate the hepatic vein at this stage. The liver parenchyma is divided using the radiofrequency dissector to expose moderate-sized veins that are clipped and divided. The CUSA dissector is used for parenchymal division in both laparoscopic and open liver resection. As the liver parenchyma is divided, the segment 3 pedicles are exposed and divided using an Endo-GIA vascular stapler. The hepatogastric ligament is divided to expose the caudate lobe and provide access to the posterior aspect of the main pedicles. The main pedicle to segment 3 is now divided using a vascular stapler.
  • 03'59" Vascular control of segment III of liver
    We find that a combination of radiofrequency and ultrasonic dissection is most efficient in dividing the liver parenchyma. This provides a dry field with minimal blood loss and is more efficient than either technique in isolation. A large tributary of the left hepatic vein is encountered draining the tumor and is gently exposed by a combination of CUSA and radiofrequency dissection, then divided with a vascular stapler. The superior part of the hepatogastric ligament is divided to expose the main pedicle to segment 2, and this is transected with a vascular stapler. The left lobe of the liver is now almost fully resected but remains attached only via the left hepatic vein.
  • 05'11" Left hepatic vein
    For laparoscopic liver resections, our practice is to isolate and divide the major hepatic veins using an intra-hepatic approach. The left hepatic vein is cleared of tissue and divided using the endovascular GIA stapler. This releases the specimen and the operative site is gently irrigated with warm saline. In this patient, an aberrant left hepatic artery has been preserved to supply segment 4.
  • 05'52" Argon beam and biological glue
    As in open surgery, the residual liver parenchyma is coagulated with Argon plasma to reduce the risk of postoperative bleeding. And finally the liver is sprayed with a biological glue to minimize the risk of postoperative bile leak. A large port is placed in the left iliac fossa and a retrieval bag introduced to retrieve the resected specimen.
  • 06'30" Specimen extraction
    The specimen is gently placed into the retrieval bag, the draw string tightened and the port site extended in the left iliac fossa to enable extraction of an intact specimen.
  • 07'08" End of procedure
    The port sites are shown here with the working ports 1 to 3 placed centrally to correspond to the line of parenchymal transection. This patient is on the 2nd postoperative day after a laparoscopic left lobectomy. The abdominal drain is normally removed on day 2 and patient is discharged on day 4 after laparoscopic liver resection. This patient had a left hemicolectomy through the midline abdominal incision one year prior to his laparoscopic liver resection.
  • Related medias
    This video demonstrates a left hepatic lobectomy of segments 2 and 3 in a patient with a large secondary lesion from a colon cancer. The video demonstrates the access to the vascular pedicles of segments 2 and 3 before division using a stapler. The liver parenchymal division was done with CUSA. The left hepatic vein was divided last after full mobilization of the lobes. The cut surface of the liver was sealed with Argon laser and sealant glue.