A case report of Fontan procedure-related hepatocellular carcinoma: pure laparoscopic approach by low and stable pneumoperitoneum

Abstract

Background: The Fontan procedure has become the standard operation for patients with single ventricle physiology. Due to cardiac hypokinesis and high central venous pressure, laparoscopic approach, especially in hepatectomy, was considered as controversial after the Fontan procedure. We presented a case of hepatocellular carcinoma (HCC) that was successfully treated by pure laparoscopic hepatectomy with stable pneumoperitoneum after the Fontan procedure. Case presentation: An 18-year-old man was referred to our hospital for examination of a hepatic tumor. The patient underwent the Fontan procedure for single ventricle physiology at 6 years of age. Abdominal contrastenhanced computed tomography (CT) revealed a hypovascular mass in segment 2 and a hypervascular mass in segment 4 of the arterial phase, followed by a delayed washout. CT arteriography revealed that both masses showed hypervascular tumors, and CT during arterial portography showed that both were low-density masses. The patient's general condition was good, and cardiac and respiratory functions were well maintained. Pure laparoscopic hepatectomy was safely performed by keeping the pneumoteritoneum pressure under 6-8 mmHg and monitoring central venous pressure (11-21 mmHg) and end-tidal carbon dioxide. The Pringle maneuver was applied during hepatic resection. The non-anatomical resections were completed without intraoperative complications. The patient was discharged on the 9th postoperative day without postoperative complications. Conclusions: Our report suggests that treatment of HCC by pure laparoscopic hepatectomy after Fontan circulation can be safely performed in patients under sufficient circulatory management.

Fontan-associated liver disease and hepatocellular carcinoma in adults

“…This procedure reduced the CVP from 12 to 10 mmHg without decreasing the systemic blood pressure resulted in reduced blood loss. Moreover, laparoscopic hepatectomy was reported as safe proceasear in the FALD setting 64 , 65 . The laparoscopic hepatectomy was safely performed keeping the pneumoperitoneum pressure at less than 6–10 mmHg and adequate fluid infusion was given to maintain cardiac preload 64 .…”

“…The laparoscopic hepatectomy was safely performed keeping the pneumoperitoneum pressure at less than 6–10 mmHg and adequate fluid infusion was given to maintain cardiac preload 64 . Central venous pressure was monitored (11–21 mmHg) and end-tidal carbon dioxide tension was shifted to 36–40 mmHg 65 . The Pringle maneuver was applied during liver resection.…”

Laparoscopic partial liver resection for hepatocellular carcinoma arising from Fontan-associated liver disease: a case report

“…Most cases of HCC arising from FALD are reportedly treated non-surgically, with poor liver function reducing the tolerance for surgical resection [ 11 ]. However, recent improvements in surgical procedures and perioperative management have enabled safe liver resection not only by laparotomy, but also in laparoscopic surgery [ 12 , 13 ]. The present case appears to represent the third report of laparoscopic liver resection for HCC arising from FALD [ 12 , 13 ], but the first case in which the origin of a hepatic vein was exposed.…”

“…Laparoscopic surgery shows some limitations for patients who have undergone FP. Laparoscopic surgery easily leads to low cardiac output due to the elevations in intrathoracic and intraabdominal pressures under positive-pressure ventilation and pneumoperitoneum [ 12 , 13 ]. Nonetheless, although CVP was elevated after the initiation of pneumoperitoneum in our case, blood pressure was kept stable.…”

A Case Report of Hepatocellular Carcinoma Derived from Rastelli Procedure-Related Congestive Liver Disease

“…The Fontan operation is applied in the case of a single ventricle and involves separation of the pulmonary circulation from the systemic circulation. The Fontan physiology after surgery can lead to elevated systemic venous pressure and diminished cardiac output, leading to liver brosis and HCC with the duration of the Fontan circulation [5] , [6]. However, to the best of our knowledge, there have been no reports of HCC with congestive liver brosis after the Rastelli operation.…”