Left lateral liver resection, laparoscopic - general and visceral surgery

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.

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.

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.

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.

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.

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.

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.

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.

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.