Laparoscopic left lateral hepatic lobectomy: a safer and faster technique.
ABSTRACT Laparoscopy for liver resection is highly specialized field because laparoscopic liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. At present, a limited number of laparoscopic anatomical left lobectomies have been reported in the literature, but we believe that the use of stapling devices has made this technique safer and faster.
From January 2000 to May 2005, eight patients (five men, three women; mean age, 60.5 years) underwent laparoscopic anatomical left lobectomy at our department. Seven patients presented with hepatocellular carcinoma and cirrhosis, while one patient had a large symptomatic angioma. The average size of the lesions was 4.18 cm (range, 3.6-7.1 cm); all the lesions were localized in the anatomical left lobe (segments II-III). Transection of the liver parenchyma, together with sectioning of the vascular pedicle for segment II and III and of the left hepatic vein, was obtained by the use of stapling devices.
The mean operative time was 142 min (range, 120-180 min). There were no intraoperative or postoperative complications, and blood transfusions were not required. The mean postoperative hospital stay was 5.75 days.
The key points of the technique are: late mobilization of the liver; no transection of the round ligament; no surrounding or taping of the portal pedicles or of the left hepatic vein; and the use of three consecutive linear staplers, turned to the left for transecting the liver parenchyma and vascular pedicle together. This technique, in our opinion, should be considered a new good option for patients with isolated lesions of the left lateral segments, but it must be performed by surgeons trained in both liver and advanced laparoscopic surgery.
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ABSTRACT: The continuing evolution of technique and devices used in laparoscopic liver resection (LLR) has allowed successful application of this minimally invasive surgery for the treatment of liver disease. However, the type of instruments by energy sources and technique used vary among each institution. We reviewed the literature to seek the best technique for parenchymal transection, which was proposed as one of the important clinical question in the 2nd International Consensus Conference on LLR held on October 2014. While publications have described transection techniques used in LLR from 1991 to June 2014, it is difficult to specify the best technique and device for laparoscopic hepatic parenchymal transection, owing to a lack of randomized trials with only a small number of comparative studies. However, it is clear that instruments should be used in combination with others based on their functions and the depth of liver resection. Most authors have reported using staplers to secure and divide major vessels. Preparation for prevention of unexpected hemorrhaging particularly in liver cirrhosis, the Pringle's maneuver and prompt technique for hemostasis should be performed. We conclude that hepatobiliary surgeons should select techniques based on their familiarity with a concrete understanding of instruments and individualize to the procedure of LLR. © Japanese Society of Hepato-Biliary-Pancreatic SurgeryJournal of Hepato-Biliary-Pancreatic Sciences 01/2015; 22(5). DOI:10.1002/jhbp.216 · 2.31 Impact Factor
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ABSTRACT: This work describes a safe and feasible technique for a total laparoscopic left hepatectomy in Bama Miniature Pigs. A purely laparoscopic four-port approach was created in generally anesthetized pigs. A polyethylene loop was installed on the left two lobes for traction and lift, and then a penetrating ligation of the lobes consisting of a double row of silk sutures was used to control bleeding. A direct hepatic transection was completed using a monopolar hook electrode without meticulous dissection of the left hepatic vein. The raw surface of the liver was coagulated and sealed with fibrin glue. Lobes were retrieved through an enlarged portal. The laparoscopic hepatic lobectomy procedures were completed in all pigs without the use of specialized instruments, and with a mean operative time of 179 ± 9 min. There were no significant occurrences of perioperative complications, and the resected liver lobes weighed 180 ± 51g. Main CBC results, serum organics and enzyme (T-Bil, γ-GT, AST, A/G) levels corrected after about 2 weeks. Necropsy showed the adhesion of the hepatic raw surface to the gastric wall and omentum; otherwise, no other abnormalities were identified. This minimally invasive left hepatectomy in swine could serve as a useful model in investigations of liver diseases and regeneration, and offers preclinical information to hepatobiliary surgery.Journal of Veterinary Science 06/2014; 15(3). DOI:10.4142/jvs.2014.15.3.417 · 1.14 Impact Factor
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ABSTRACT: Despite inception over 15 years ago and over 3000 completed procedures, laparoscopic liver resection has remained mainly in the domain of selected centers and enthusiasts. Requirement of extensive open liver resection (OLR) experience, in-depth understanding of anatomy and considerable laparoscopic technical expertise may have delayed wide application. However healthy scepticism of its actual benefits and presence of a potential publication bias; concern about its safety and technical learning curve, are probably equally responsible. Given that a large proportion of our work, at least in transplantation is still OLR, we have attempted to provide an entirely unbiased, mature opinion of its pros and cons in the current invited review. We have divided this review into two sections as we believe they merit separate attention on technical and ethical grounds. The first part deals with laparoscopic liver resection (LLR) in patients who present with benign or malignant liver pathology, wherein we have discussed its overall outcomes; its feasibility based on type of pathology and type of resection and included a small section on application of LLR in special scenarios like cirrhosis. The second part deals with the laparoscopic living donor hepatectomy (LDH) experience to date, including its potential impact on transplantation in general. Donor safety, graft outcomes after LDH and criterion to select ideal donors for LLR are discussed. Within each section we have provided practical points to improve safety in LLR and attempted to reach reasonable recommendations on the utilization of LLR for units that wish to develop such a service.