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Pure laparoscopic posterior sectionectomy and wedge resections for bilobar colorectal liver metastases

P Pessaux, MD, PhD J Hallet, MD, FRCSC R Memeo, MD, PhD D Mutter, MD, PhD, FACS J Marescaux, MD, FACS, Hon FRCS, Hon FJSES, Hon FASA, Hon APSA
Epublication WebSurg.com, Jan 2015;15(01). URL: http://websurg.com/doi/vd01en4363

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  • 2015-01-15
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We report the case of a 74-year-old gentleman who underwent a laparoscopic liver resection for bilobar colorectal liver metastases. The patient presented with newly diagnosed liver metastases one year after undergoing a right hemi-colectomy followed by six cycles of adjuvant chemotherapy for a T3N1 adenocarcinoma. After six cycles of preoperative systemic therapy, a 30 percent reduction in the volume of the liver lesions is obtained. Preoperative three-dimensional reconstruction of the cross-sectional imaging is obtained to plan a laparoscopic liver resection. Virtual hepatectomy is then performed using the virtual three-dimensional model. Five trocars are used as depicted. The camera is initially positioned in a 10mm umbilical port. It will be placed in a 12mm port during parenchymal transection. The subxiphoid port is used by the assistant for liver traction and suctioning. The procedure is initiated by lyzing adhesions that resulted from the previous cholecystectomy and right hemi-colectomy. An umbilical tape is placed around the portal pedicle for eventual intermittent clamping during the resection. An intraoperative ultrasound confirms that no additional lesions are present. The transection line is drawn on the liver surface under ultrasound guidance. The portal pedicle is clamped to begin the parenchymal transection. The liver capsule is first divided using an energy device. Deeper parenchymal transection is performed with an ultrasonic dissector. After 15 minutes, the pedicle clamping is taken down by melting and extracting the proximal clip previously placed. This procedure will be repeated throughout the parenchymal transection to obtain a posterior sectionectomy. Hemostasis of the transected liver is obtained. A non-anatomical segment III resection is then performed. Finally, the fourth lesion is resected with a non-anatomical segment IV resection. These specimens are placed in a bag and extracted through a small extension of the umbilical port.