Left lateral liver resection, laparoscopic

  • MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

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  • Functional liver anatomy

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    In terms of surface relations, on the superior parietal surface the insertion of the ligamentum teres and the falciform ligament, and the sagittal fissure on the inferior aspect divide the liver into a large right and small left lobe (about 80:20 by volume), this gross anatomical division does not correspond with the functional anatomy of the liver.  The functional structure of the liver is governed by the branches of the structures in the porta hepatis: Portal vein, hepatic artery and hepatic duct. Not only do these three anatomical structures branch, mostly in matching fashion, in the porta hepatis but also in the hepatic parenchyma. Because the blood supply and bile drainage of each hepatic segment are completely independent of all other segments, each segment may be resected without compromising the function of the remaining liver.

    Therefore, the concept of “functional anatomy” refers to the hepatic substructure based on circumscribed, hemodynamically independent areas of parenchyma, the knowledge of which is essential for surgical strategy in liver resections.

  • Portal vein and hepatic veins

    The functional structure of the liver rests on the portal vein ramifying into individual, completely independent subunits, the liver segments.

    In the porta hepatis, the portal vein usually bifurcates into a left and right lobar branch.The outer margin of these areas is defined by Cantlie’s line, i.e., the vertical plane extending from the inferior vena cava posteriorly to the middle of the gallbladder fossa anteriorly. The right lobar branch divides into an anteromedial and posterolateral branch supplying the liver segments V/VIII and VI/VII respectively. The left lobar branch of the portal vein courses transversely to the left, continuing anteriorly as umbilical branch and terminating at the insertion of the ligamentum teres in the recessus of Rex. The left lobar branch of the portal vein gives off branches to both left lateral segments II and III, and to the median segments IVa and IVb as well. The small caudate lobeis special because it may receive sizable tributaries from the left and right lobar branch of the portal vein.

    Couinaud identified eight portovenous liver segments which are numbered clockwise starting with the caudate lobe:

    Segment I………………………..caudate lobe

    Segments I/II/III………………… left lateral hepatic lobe

    Segment IV………………………left paramedian sector (quadrate lobe)

    Segments I/II/III/IV………………left lobe of liver

    Segments V/VIII…………………right paramedian sector

    Segments VI/VII…………………right lateral sector

    Segments V/VI/VII/VIII………….right lobe of liver

    Three major venous trunks traverse the liver caudocephalad; these are the right, median and left hepatic veinswhich divide the liver into a total of four hepatic sectors.The left hepatic vein almost exclusively drains the left lateral hepatic lobe, and just before its junction with the inferior vena cava it usually merges with the middle hepatic vein which courses along the cava-gallbladder line. The right hepatic vein travels between the posterolateral and anteromedial segments. The caudate lobe has its own venous drainage, the Spieghelian veins, comprising multiple small posterior veins draining directly into the inferior vena cava.

    In reality, the regularity of the venous branching described by Couinaud is seen only in few cases, and there are numerous branch variants supplying areas of varying size.

    The portal hila of liver segments II, III and IV are extrahepatic and can be easily exposed in the anterior section of the left umbilical fissure. The portal hila of the right liver segments are intrahepatic; while there are exceptions at times, these mostly pertain to segment VI. The anatomy of the hepatic veins is even more variable than that of the portal vein.

  • Hepatic artery

    While normally the common hepatic artery arises from the celiac axis, in rare cases its origin is directly with the aorta or superior mesenteric artery. After giving off the gastroduodenal artery, the proper hepatic artery bifurcates in the porta hepatis into the left and right hepatic arteries. Quite often, there are even more extrahepatic branches, such as the artery for liver segment IV, which usually arises from the left hepatic artery just before the umbilical fissure. Variants of this normal anatomy of the hepatic arteries have been described in about 30% of cases.

  • Bile ducts

    The extrahepatic section of the left hepatic duct is about 3 cm to 5 cm long and arises in the umbilical fissure from the junction of the two bile ducts draining segments II and III.In most cases the bile duct from segment IV will join proximal to this junction. With about 25%, the most common anatomical variant is a common junction of the bile duct from segment IV with those bile ducts draining segments II and III. This variant has clinical ramifications in left hemihepatectomy, split liver and living-donor liver transplants because it may easily impair the bile drainage from segment IV.

    Barely 1 cm long, theright hepatic duct is rather short and drains bile from segments V, VI, VII and VIII via an anterior and posterior branch.Sometimes the right hepatic duct may be missing altogether. The variant junctions of the posterior branch are clinically relevant because this branch may empty directly into the cystic duct, common hepatic duct or common bile duct.

  • Regional lymph nodes

    The liver has two lymphatic systems:

    1. Most of the liver lymph (90%) drains into the lymph nodes at the porta hepatis and from there via the celiac lymph nodes into the intestinal trunk.

    2. The second system, a subserous network of lymphatics (10%), drains the superficial aspects of the phrenic surface and the area nuda. The lymph passes through the diaphragm into the superior phrenic lymph nodes and from there via mediastinal lymphatics into the right venous angle.

  • Klinikum Bogenhausen

    Dr. med. Ehrl

  • Helios Amper-Klinikum Dachau

    Prof. Dr. med. Horst-Günter Rau

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 25.12.2012
  • Klinikum Bogenhausen

    Dr. med. Ehrl

  • Helios Amper-Klinikum Dachau

    Prof. Dr. med. Horst-Günter Rau

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  • Establishing the pneumoperitoneum, inserting the trocar for laparoscope and exploring the upper quadrants

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    Skin incision about two or three finger breadths superior to the umbilicus; insert the Verres needle and establish pneumoperitoneum with 13mmHg under pressure control. Insert a 10mm shielded trocar Insert the laparoscope and explore the upper quadrants: There is an inflamed conglomerate mass; at its superior aspect the left hepatic lobe adheres to the diaphragm, while its inferior aspect is caked with the stomach and greater omentum.

  • Inserting the working trocars, transecting the round and falciform ligaments of the liver

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    Under endoscopic view insert a 12mm trocar in the left upper quadrant and a 5mm trocar at the same level in the right upper quadrant. With the UltraCision Harmonic Scalpel® transect both the round and falciform ligaments of liver close to the abdominal wall.

  • Freeing the liver

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    Inflammatory changes make it rather difficult to free the left hepatic lobe. This requires freeing the liver step by step from adhesions with the diaphragm until the left hepatic vein has been freed. Due to extensive adhesions it is impossible to identify the triangular ligament as such. Both the stomach and the lesser omentum also display extensive adhesions with the visceral aspect of the left hepatic lobe. Detach the stomach from the inferior aspect of the liver, free the hepatic hilum and open up the lesser omentum all the way to the diaphragm.

  • Local findings: Intraoperative ultrasonography (IOUS)

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    Exchange the 12 mm trocar in the left upper quadrant against a 15 mm trocar for insertion of the ultrasound probe. IOUS allows detection of additional tumor findings as well as assessment of the intrahepatic course of vessels. This permits inferences regarding resectability and assessment of the possible safety margin around the hepatic mass and therefore helps significantly in determining the resection margins. During the examination depicted in the video a thrombus is seen within a branch of the portal vein.

  • Starting parenchymal resection, transecting the portal vein and hepatic artery

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    Transect the parenchyma along the left margin of the falciform ligament from the anterior margin to where the left hepatic vein enters the inferior vena cava.

    Note: To prevent injury to the pedicle (branch of the portal vein, hepatic artery and common hepatic duct) to segment IV, it is important to keep the line of transection on the left side of the ligament.

    With a wide laparoscopic retractor (Endo Paddle Retract™, 12mm instrument, subxiphoid access) the tumor carrying lateral segments are retracted to the left. When transecting the parenchyma with the Ultracision, start with the parenchymal bridge between segments IV and III. For the basal hilar dissection of the segment staple the pedicle (angled stapler, blue cartridge).

    Tip: To ensure sufficient coagulation close the Ultracision branches very slowly and without any force. Soft parenchyma lends itself quite well to transection with the water-jet dissector; its advantage is less aerosol formation compared with the Ultracision.

  • Continue dissecting the parenchyma and transecting the left hepatic vein

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    You are now advancing into the parenchyma and can successively dissect along the segment margins up to the left hepatic vein.

    Posteriad the transection line follows the anterior margin of the venous ligament (Arantius ligament) between the caudate lobe and segment II; around the segment hilum a linear stapler may be used once again.

    Note: When detaching the caudate lobe, make sure to spare the small branches of the portal vein and bile duct to the caudate lobe. Otherwise this could lead to unpleasant postoperative bile fistulas.

    Continue dissecting the parenchyma until the left hepatic vein has been identified. Near the hepatic vein a small vein has been opened and is sutured laparoscopically.

    Now transect the left hepatic vein, together with its surrounding last parenchyma bridge, with the linear cutter (angled, white cartridge). Once the last attachments with the stomach have been transected, the hepatic lobe is completely free.

  • Sealing the resection area with a collagen sponge and inserting a Robinson drain

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    Once the resection area has been checked for hemostasis it is sealed with a collagen sponge. Insert a Robinson drain along the resection area up into the left upper quadrant and secure it with a skin suture.

  • Retrieving the specimen

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    Insert a retrieval bag and place the specimen in it. Widen the incision at the 15mm trocar site such that the very large specimen (tumor diameter > 10cm) can be retrieved.

  • Closing the abdominal wall

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    Layered wound closure of the transverse incision with continuous sutures of the peritoneum, fascia and skin. Close each of the remaining trocar sites with one suture of the fascia and skin each.

  • Klinikum Bogenhausen

    Dr. med. Ehrl

  • Helios Amper-Klinikum Dachau

    Prof. Dr. med. Horst-Günter Rau

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  • Prevention and management of intraoperative complications

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  • Prevention and management of postoperative complications

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  • Klinikum Bogenhausen

    Dr. med. Ehrl

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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Reviews

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  • Literature search

    Literature search under: http://www.pubmed.com