Color Atlas of Laparoscopic Liver Resection

67 Pages·2021·10.664 MB·English

by  Ho-Seong Han, Jai Young Cho

Ho-Seong Han
Jai Young Cho
Color Atlas of
Laparoscopic Liver
Resection
Color Atlas of Laparoscopic Liver Resection
Ho-Seong Han • Jai Young Cho
Color Atlas of Laparoscopic
Liver Resection
Ho-Seong Han Jai Young Cho
Seoul National University Bundang Hospital Seoul National University Bundang Hospital
Seoul National University College of Medicine Seoul National University College of Medicine
Department of Surgery Department of Surgery
Seoul, Korea (Republic of) Seoul, Korea (Republic of)
ISBN 978-981-16-1545-0 ISBN 978-981-16-1546-7 (eBook)
https://doi.org/10.1007/978-981-16-1546-7
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Preface
The introduction of laparoscopic surgery can be one of the most dramatic changes in the his-
tory of the surgery. This surgery has benefitted the patients with less pain, rapid recovery, and
better cosmesis. However, laparoscopic liver surgery is the latest to be developed due to its
steep learning curve. In spite of a few decades of history, it is still not easy to perform major
liver resection and parenchymal transection in superior posterior lesions. And there is still a
risk of massive bleeding, which may lead to fatal conditions. Therefore, the operative tech-
nique in laparoscopic liver surgery is very important to all surgeons involved in liver surgery.
The first and second international consensus conferences have initiated big surges in this field.
Many liver surgeons have got interested in this surgery. Reports on the surgery have sharply
increased. And the laparoscopic left lateral sectionectomy and minor resection have become a
standard procedure. However, there has also been caution that we should be careful when per-
forming major liver resection. The International Laparoscopic Liver Society was established to
standardize the surgery and propagation of the techniques. Although there has been rapid
development in this surgery, we still have to go a long way to reach our goal.
In our center, we have tried to show that this surgery can be performed safely and metic-
ulously. In this regard, we have reported all types of laparoscopic anatomic surgery with
video clips in various journals. The contents of this atlas are a collection of our previous
reports on operative procedures and videos. For a better understanding of operative proce-
dures, each content is linked with video clips. Some videos were edited a long time ago,
and the quality of images may not be satisfactory. I hope that we can provide better quality
video in the future.
For this atlas, my coauthor Dr. Jai Young Cho has dedicated a lot. He has designed and filled
up all the contents with his passion and energy. Without him, this atlas cannot be possible. My
international fellows, Dr. Mizelle D’Silva, Dr. Kovid Nepal, Dr. Mosteanu Benone-Iulian, Dr.
Yelran Taupyk, and Dr. Mohamed Rabie, have contributed a lot in completing this atlas when
they are working with me. My junior colleague Dr. Boram Lee has helped in final editing. And
I sincerely appreciate my colleagues, Dr. YoungRok Choi, Dr. Yoo-Seok Yoon, Dr. Hae Won
Lee, and Dr. Jun Suh Lee, for their persistent support. During the preparation of this atlas, I
have got immense help and support from my colleagues and friends all over the world. I am so
blessed that I have them.
I hope that this atlas will help many liver surgeons in their pursuit of better surgery.
Seoul, Korea (Republic of) Ho-Seong Han
June 17, 2021
v
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Part I Basic Skills
Patient Positioning and Trocar Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Bleeding Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Glissonean Approach versus Individual Ligation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Application of Indocyanine Green (ICG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Part II S pecific Liver Resection
Left Lateral Sectionectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Anatomical Liver Resection in Segments 2 or 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Anatomical Liver Resection in Segment 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Left Hepatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Right Hepatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Right Posterior Sectionectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
Anatomical Liver Resection in Segments 5 or 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Right Anterior Sectionectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45
Anatomical Liver Resection in Segments 6 or 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
Central Bisectionectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Caudate Lobectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
Hepatic Cyst Unroofing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Donor Right Hepatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
vii
Introduction
Over the past 30 years, laparoscopy has emerged into the lat- As LLR is a new emerging technique there is no level 1
est trend in surgery proving to be safe and effective treatment evidence available due to lack of adequate RCTs. Hence
method, possibly superior to the traditional open surgery. committee discussed the safety of the procedure based on
With advancement comes adoption of new technology and existing literatures, although there are few available RCTs.
training in new techniques. Laparoscopy has advanced from Acceptable indications for LLR were to be
laparoscopic appendectomy and cholecystectomy to bariat-
ric surgery, fundoplication, nephrectomy, colonic anterior 1. Solitary lesions, 5 cm or less, located in liver segments
resection, and finally up to liver surgery. 2–6
However, it is interesting to note that though laparoscopic 2. Left lateral sectionectomy
liver surgery is gaining ground in the twenty-first century the
first laparoscopic liver resection (LLR) was performed way Liver resections were divided into two categories: major
back in 1991, LLR is gaining ground three decades later. and minor. Minor resection is the category in which two or
Since liver surgery is technically challenging operation, LLR fewer Couinaud segments are removed. Major resection to
was considered as an unsafe procedure because of fear of the one in which three or more segments are removed.
compromising oncological safety and difficulties of the pro- Operation difficulties level is not considered when cate-
cedure. Therefore, early indication of LLR used to be exci- gorizing major and minor resection. Left lateral sectionecto-
sion of small benign tumors. mies, or resections of segments 2, 3, 4b, 5, and 6 will be
In 1996, Dr. Azagra and Dr. Kaneko reported the first naturally categorized as minor resection. Even resection on
series of laparoscopic anatomical resection, particularly posterior superior segments will be considered as minor
left lateral sectionectomy. First hemihepatectomy was resection.
reported in 1997 by Huscher et al. The first case of laparo- After the first ICCLLR, the propagation of the LLR has
scopic right posterior sectionectomy was reported in 2006 been more increased. Many surgeons and centers have inter-
from our center. est in performing LLR. Laparoscopic left lateral and left
With dramatic development of surgical techniques and hemihepatectomy have become popular procedures, with
laparoscopic equipment, difficult procedures such as hemi- increasing number of institutes performing major resection.
hepatectomy, right posterior sectionectomy, caudate lobe The second International Consensus Conference on
resection are being performed laparoscopically. Laparoscopic Laparoscopic Liver Resection (ICCLLR) was held on 4th–
surgeons have now ventured into the field of liver transplant 6th October 2014, in Morioka, Japan. During this consen-
with even donor hepatectomy. sus, a jury of expert hepatobiliary surgeons from different
One of the biggest accomplishments in laparoscopic liver countries was called upon to better define the current role
surgery was organizing the International Consensus of LLR and to develop internationally acceptable recom-
Conference on Laparoscopic Liver Resection (ICCLLR). mendations. 17 questions were discussed in terms of value,
The First ICCLLR was convened on 7th–8th November technique, and short-term outcomes. The most important
2008 in Louisville, Kentucky, USA. Forty five experts of message from the ICCLLR was to protect patients from
open and laparoscopic liver surgery were in attendance. this new surgical procedure. The ICCLLR recommended
© Springer Nature Singapore Pte Ltd. 2021 1
H.-S. Han, J. Y. Cho, Color Atlas of Laparoscopic Liver Resection, https://doi.org/10.1007/978-981-16-1546-7_1
2 Introduction
caution for major resection due to novelty of this new sur- tive of surgeons at a high-volume center (Fig. 2). This rec-
gical procedure: ommendation panel was devised based on the tumor location
For online prospective registry, the operator of LLR is and type of resection. The highest level of difficulty is given
requested to fill up simple items at four time points, i.e. pre- a score of 7 points, according to this scoring system. Five
operation, after-operation, after discharge, and readmission other elements are considered together with that factor to
if it happens. The system incudes items to calculate the dif- determine the final score; tumor size, tumor number, tumor-
ficulty score so that the operator can recognize the difficulty vessel relationships, liver function and previous surgery
of planned LLR preoperatively. (Fig. 3). Finally, the highest possible score is 12. LLR proce-
The expert panel proposed criteria (IWATE criteria), dure are categorized into four classes (Fig. 4). The first cat-
which is determined by tumor location, tumor size, proxim- egory is ‘Strongly Recommended’ LLR, in which the patient
ity of major vessels, extent of liver resection, HALS/Hybrid would probably benefit most from a minimally invasive
and liver function. The summed up score can be used to pre- approach: small tumor, located in an anterior segment,
dict the difficulties of LLR (Fig. 1). removed in a nonanatomic fashion (score 1–2). The second
Han et al. reported a simple-to-use recommendation score category is ‘Recommended’ LLR, for which the conditions
based on the current indication for LLR, from the perspec- require nonanatomic resection or anatomic resection without
Difficulty scoring system
Difficulty index 0 1 2 3 4 5 6 7 8 9 10 11 12
Difficulty level Low Intermediate Advanced Expert
Right or left hepatectomy
Left lateral sectionectomy
Index surgery
Simple and small partial hepatectomy in segment III Posterior sectionectomy for segment VII tumor >_ 3 cm
Scoring system
Tumor location (Couinaud segment) Tumor size
Segment Score Score
IVa 2 II
VIII 4 <3 cm 0
5 1 S1 4
S2 2 >_3 cm 1
IVb 3 III S3 1
S4a 4 Proximity to major vessel*
5VII V S4b 3
3 S5 3 Score
4 S6 2 No 0
I S7 5
Yes 1
2 S8 5
VI
*Main or second branch of Glisson’s tree,
major hepatic vein, or inferior vena cava
Extent of liver resection HALS/Hybrid Liver function
Score
Score Score
Partial resection 0
No 0 Child Pugh A 0
Left lateral sectionectomy 2
Segmentectomy 3 Yes –1 Child Pugh B 1
Sectionectomy and more 4
Fig. 1 Difficulty scoring system from HBSN 2016
Introduction 3
associated risk factors, such as cirrhotic liver or previous
Easy Moderate Difficult Very difficult
abdominal surgery. We believe these patients will still benefit
Resection Point 1 2 3 4
extent from a minimally invasive approach, and most surgeries can
Non- 0 S3, S4B, S5 S2, S4A, S6 NAR S1C1, S7, S8 S1Pc NAR be successfully completed with this approach (score 3–4).
Anatomical NAR NAR
resection The third category is ‘Weakly Recommended’ LLR, includ-
LLS
ing tumors of >3 cm in diameter, located deeply, or in con-
Anatomical 1 S2, 3, 5, S6 AR S4AR S1, S7, S8 AR tact with major vessels. These cases should not be routinely
resection
treated with a laparoscopic approach, and an expert surgeon
Major 2 LH RH Ext. LH is required (score 5–6). The fourth category is ‘Very Weakly
resection Ext. RH
Recommended’, which includes patients with multiple risk
Complicated 3 RAS CBS factors. In such cases, the minimally invasive approach
resection RPS
should only be performed exceptionally, by very experienced
surgeons (score > 7).
S: Segment; NAR: non-anatomical resection; LLS: left lateral sectionectomy; C1: caudate lobe; Pc: It is necessary to focus on training surgeons in laparo-
paracaval; AR: anatomical resection; LH: Left Hepatectomy; RH: Right Hepatectomy; Ext.: extended;
RAS: right anterior sectionectmy; RPS: right posterior sectionectomy; CBS: central bisectionectomy. scopic skills especially for major hepatectomy, due to steep
learning curve required. A formal structure of education
Fig. 2 The grade of difficulty
needs to be created.
According to a study published by Villeni et al., the learn-
ing curve for LLR follows an uneven pattern with alternate
Tumor number >2 +1 periods of improvement and regression till the surgeon
reaches a plateau from where no further improvement is pos-
Cirrhosis +1
sible. The periods of regression are probably due to overcon-
Tumor size >3cm +1
fidence once a stage of improvement has been reached.
Tumor in contact or invading major vessel +1
Hence the surgeon needs to be vigilant during the entire
Previous abdominal surgery +1 training process till the plateau phase has been reached.
Fig. 3 The factors which affect the difficulty to the operation 1. Caudal approach rather than anterior approach. It gives
improved exposure of the IVC and helps in identification
of Laennec’s capsule and Glissonian pedicle at the hilar
plate. Caudal-cranial transection of liver parenchyma
helps in better identification of intraparenchymal struc-
tures along with added magnification.
2. CO2 pneumoperitoneum helps in reducing bleeding from
hepatic veins. Decreasing air pressure by temporary stop-
page of artificial ventilation helps to reduce backbleeding.
3. Trendelenberg position helps decrease venous pressure
and improves exposure by using gravity.
4. Left Interal decubitus position offers better exposure of
the right posterior segments and lifts right hepatic vein
higher than IVC so as to reduce hepatic venous bleeding.
International meeting on donor hepatectomy was held dur-
ing the 26th World Congress of the International Association
of Surgeons, Gastroenterologists and Oncologists (IASGO)
in Seoul, South Korea in 2016.
The expert panel discussed on laparoscopic living donor
hepatectomy and concluded the role of laparoscopic donor
hepatectomy will increase in both adult and pediatric age
group. The first laparoscopic Donor right hepatectomy was
Fig. 4 Recommendation levels of Laparoscopic liver resection performed in early 2010 by our center.
4 Introduction
Another area of discussion was cirrhotic patients. LLR Cho JY, Han HS, Wakabayashi G, Soubrane O, Geller D, O’Rourke N,
Buell J, Cherqui D. Practical guidelines for performing laparoscopic
was found to have increasing advantages for cirrhotic patients
liver resection based on the second international laparoscopic liver
with a lower incidence of post-operative liver failure and
consensus conference. Surg Oncol. 2018;27:A5–9.
ascites due to less liver manipulation and preservation of Han HS, Cho JY, Kaneko H, Wakabayashi G, Okajima H, Uemoto S,
abdominal musculature with smaller incisions. et al. Expert panel statement on laparoscopic living donor hepatec-
tomy. Dig Surg. 2018;35(4):284–8.
International Laparoscopic Liver Society (ILLS) was offi-
Kaneko H, Takagi S, Shiba T. Laparoscopic partial hepatectomy and
cially launched at the IHPBA meeting in Sao Paulo in April
left lateral segmentectomy: technique and results of a clinical series.
2016. The first meeting was held in Paris in 2016 and decided Surgery. 1996;120:468–75.
to hold meeting biannually. Shehta A, Han HS, Yoon YS, Cho JY, Choi Y. Laparoscopic liver resec-
tion for hepatocellular carcinoma in cirrhotic patients: 10-year
Although, LLR has a rapid growth in the last several
single-c enter experience. Surg Endosc. 2016;30:638–48.
years, the surgery is still limited to high volume centers with
Wakabayashi G. What has changed after the Morioka consensus con-
experienced surgeons. The next challenge of LLR is stan- ference 2014 on laparoscopic liver resection? Hepatobiliary Surg
dardization of the procedures and systematic training of Nutr. 2016;5(4):281–9.
Yoon YS, Han HS, Choi YS, Jang JY, Suh KS, Kim SW, et al. Total
young surgeons. Training in both hepatobiliary surgery and
laparoscopic right posterior sectionectomy for hepatocellular carci-
laparoscopic surgery is needed in order to master the tech-
noma. J Laparoendosc Adv Surg Tech A. 2006;16(3):274.
nique of LLR. Mosteanu BI, Han HS, Cho JY, Lee B. When should we choose a
laparoscopic approach? A high-volume center recommendation
score. Surg Oncol. 2020;34:208−211. https://doi.org/10.1016/j.sur-
onc.2020.04.024. Epub 2020 May 4.
Suggested Readings
Buell JF, Cherqui D, Geller DA, O’Rourke N, Iannitti D, Dagher I,
et al. The international position on laparoscopic liver surgery: the
Louisville statement, 2008. Ann Surg. 2009;250(5):825–30.