[Show abstract][Hide abstract] ABSTRACT: Laparoscopic hepatectomy has rapidly evolved recently; 1-5 however, laparoscopic anatomical hepatectomy has yet to become widely used, although anatomical hepatectomy is ideal, especially for curative treatment of hepatocellular carcinoma, and is widely accepted via open approach. 6-10 This is because good-experienced skills, for example, exposing Glissonean pedicles and hepatic veins on the cutting plane, are required in order to perform anatomical hepatectomy via a pure laparoscopic approach. We obtained good results for various totally laparoscopic anatomical hepatectomies using the standardized techniques. We exposed the major hepatic veins from the root side by utilizing the unique view from the caudal side in the laparoscopic approach, and moved CUSA from the root side toward the peripheral side to avoid splitting the bifurcation of the hepatic vein. 11-13 We performed totally laparoscopic anatomical hepatectomy for 47 patients from August, 2008, to December, 2012 (Table 1). In most types of anatomical hepatectomy, the mean blood loss was <500 ml. Conversion to open surgery was required in two patients. Postoperative complications were prolonged ascites in two, peroneal palsy in two, and biloma in one. Mortality was zero. The embedded video demonstrates totally laparoscopic right anterior sectorectomy. In conclusion, our standardized techniques make laparoscopic anatomical hepatectomy more feasible. Table 1 The result of 47 patients who underwent totally laparoscopic anatomical hepatectomy Number of cases Time (mean) Blood loss (mean) Additional procedures Conversion to open surgery Complications Rt. Hemi. 4 6 hr. 10 min. 270 g Colectomy × 1, Stoma closure × 1 0 Lt. Hemi. 4 5 hr. 06 min. 246 g S5 partial × 1 0 Rt. Ant. Sector 5 7 hr. 03 min. 596 g 0 Ascites × 2 Rt. Post. Sector 7 7 hr. 32 min. 382 g S8 partial × 2, Rt.adrenectomy × 1 0 Peroneal palsy × 1 Lt. lateral Sector 7 3 hr. 29 min. 211 g 0 Lt. Medial Sector 4 5 hr. 10 min. 310 g S8 partial × 1 0 Dorsal Rt. Ant. Segment 1 6 hr. 35 min. 395 g 0 Peroneal palsy × 1 S2 (segmentectomy) 1 7 hr. 15 min. 310 g S4 partial 0 S3 (segmentectomy) 1 3 hr. 22 min. 5 g 0 S5 (segmentectomy) 3 6 hr. 28 min. 262 g 0 S6 (segmentectomy) 4 5 hr. 00 min. 140 g 0 S5 + 6 (segmentectomy) 2 8 hr. 14 min. 765 g 0 S8 (segmentectomy) 2 8 hr. 00 min. 795 g excessive time × 2 Rt. Caudate lobe 2 8 hr. 51 min. 240 g S2 partial & Coloctomy × 1 0 Biloma × 1.
Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 05/2014;
[Show abstract][Hide abstract] ABSTRACT: Anatomical hepatectomy (AH) is basically not required for metastatic tumors in terms of oncology, but is required for hepatocellular carcinoma [1-5]; however, the surgeon cannot secure the surgical margin by palpation via a laparoscopic approach. Therefore, AH or partial hepatectomy exposing the vessels around the tumor (PHev) is often better for deep-seated or invisible lesions [6, 7] because unexpected exposure of the tumor on the cutting plane can be avoided by creating a cutting plane on the side of exposed vessels. From August 2008 to December 2012, we performed totally laparoscopic AH or PHev for 29 patients (AH in 21 patients and PHev in 8 patients) to secure the surgical margin of metastatic tumors [8, 9]. The median operative time was 329 (range 147-519) min, with median blood loss of 141 (range 5-430) g. Conversion was performed for one patient whose stump of the Glissonean branch was positive in a frozen section. Additional hepatectomy was performed via an open approach. Postoperative morbidity rate was 20.7 % (peroneal palsy in two patients, ileus in one patient, biloma in one patient, and pulmonary embolism in one patient). Mortality was zero. The median length of hospital stay after surgery was 9 (range 4-21) days. Only one patient, who underwent extended posterior sectorectomy for a 4.2-cm tumor developing close to the right main Glissonean pedicle, had a microscopically positive margin, because the tumors were exposed on the cutting plane. The embedded video demonstrates hepatectomy of the dorsal half-segment of the right anterior sector, during which the liver was divided at the anterior fissure  and the border between the anterior and posterior sector. Totally laparoscopic hepatectomy exposing the vessels around the tumor can be performed safely and is useful to secure the surgical margin in patients with a metastatic tumor.
[Show abstract][Hide abstract] ABSTRACT: Our standardized procedures for dissection of the pancreatic head from the mesenteric vessels during laparoscopic pancreaticoduodenectomy are described.
Procedures: Dissection of the pancreatic head from the mesenteric vessels is performed by peeling the pancreas from the uncinate process to the pancreatic neck clockwise from the caudal side. After Kocher’s maneuver, taking advantage of the unique laparoscopic view from the caudal side, the posterior aspect of the superior mesenteric artery beside the pancreatic uncinate process is exposed by dividing the fat tissue through the hole which has been opened in the ligament of Treitz. After passing the jejunum stump to the right side, the surgeon pulls up the pancreatic head while the assistant pulls up the tape placed at the pancreatic neck in order to pull the pancreas away from the superior mesenteric vessels radially. Maintaining this position, the uncinate process is dissected from the mesenteric vessels, mostly using only LigaSure. Lastly, the connective tissue including the nerve plexus between the pancreatic head and the celiac axis is divided, and then the right aspect of the portal vein is exposed completely and only the pancreatic neck and the common bile duct remain connected with the pancreatic head.
Conclusions: The unique laparoscopic view from the caudal side provides a magnified and closely caudal-back view of the pancreatic head, so the anatomy around the uncinate process is made easier for prehension. The current procedure taking advantage of the unique laparoscopic view from the caudal side makes laparoscopic pancreaticoduodenectomy more feasible.
Journal of the American College of Surgeons 09/2013; · 4.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Even during laparoscopic hepatectomy, a technique is often required to expose the major vessels, for example, in anatomical hepatectomy. We have standardized and performed such laparoscopic hepatectomy as successfully as open hepatectomy. METHODS: We divide the liver parenchyma without pre-coagulation, exposing the major vessels using CUSA. To control the bleeding, we keep the central venous pressure low and often perform Pringle's maneuver. Over 49 months, we performed totally laparoscopic hepatectomies in 41 patients with the technique of exposing the major vessels. These included major hepatectomy in 7, sectorectomy in 17, segmentectomy in 14, and others in 3. RESULTS: The median operative time was 361 (range 176-605) minutes, with median blood loss of 216 (range 0-1600) g. The conversion rate was 4.9 %. Postoperative morbidity rate was 9.8 % (prolonged ascites in 1, port site infection in 1, peroneal palsy in 2). Mortality was zero. The median length of hospital stay after surgery was 8 (range 5-28) days. No local recurrence was found at the time of writing. CONCLUSIONS: By using our standardized procedure exposing the major vessels, we could raise the quality of laparoscopic hepatectomy toward the level of open hepatectomy significantly.
Journal of hepato-biliary-pancreatic sciences. 12/2012;
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: While the amount of blood loss during laparoscopic hepatectomy tends to be smaller than that during open hepatectomy, intermittent vascular occlusion to control hepatic inflow can diminish blood loss during laparoscopic hepatectomy. Described herein is a useful and convenient method for intermittent vascular occlusion, which was standardized for laparoscopic hepatectomy. METHODS: A tourniquet system consisting of cloth tape and a 20-cm catheter was used for intermittent vascular occlusion. This was placed through a hole in the abdominal wall from which a 5-mm trocar had been extracted. By operating this tourniquet system outside the patient's body, we were easily able to repeat intermittent vascular occlusion. Twenty-three patients underwent laparoscopic hepatectomy using this system. RESULTS: The mean time of operation and vascular occlusion were 311.6 and 83.6 min, respectively. The mean blood loss was 215.0 mL. There were no intraoperative blood transfusions or critical postoperative complications. The average length of postoperative hospital stay was 6.5 days. The mean time to place this system was 354 s, and there were no complications caused by this system. CONCLUSION: During totally laparoscopic hepatectomy, surgeons can perform intermittent vascular occlusion safely by using this method.
[Show abstract][Hide abstract] ABSTRACT: Portal annular pancreas (PAP) is a rare anatomical anomaly in which the pancreatic parenchyma surrounds the superior mesenteric vein and portal vein (PV) annularly. This anomaly requires careful consideration in pancreatic resection. A case is presented and the technical issues are discussed. A 61-year-old female was referred to the hospital for suspected papilla Vater adenocarcinoma. Preoperative computed tomography showed that the PV was annularly surrounded by pancreatic parenchyma. Surgery revealed the uncinate process extended extensively behind the PV and fused with the pancreatic body. The pancreas was first divided above the PV, and it was divided again in the body after liberating the PV from pancreatic annulation. The postoperative course was uneventful without pancreatic fistula. It is safer to divide the pancreatic body on the left of the fusion between the uncinate process and the pancreatic body to reduce the risk of pancreatic fistula in pancreaticoduodenectomy for PAP.