Cystic hepatic lesions: No one imaging feature to rule them all

Abstract

Background: About a quarter of patients with colorectal carcinoma develop colorectal liver metastases. Surgical treatment with curative intent by hepatic resection is the standard medical care. Frequently, new liver metastasis appear during the course of their disease. Liver re-resections are usually complicated, but they represent the treatment of choice for patients with recurrent liver metastases, survival rates being similar to those achieved after the first liver resection. Methods: We present a case of a 61-year-old man with achondroplasia and history of colorectal sigmoid cancer (pT4bN0), treated with laparoscopic sigmoidectomy with and anastomosis. He was then reoperated for anastomotic leak via laparotomy and performing a terminal colostomy. Afterward, he received chemotherapy and four months later a lesion in segment 6 compatible with liver metastasis is detected. Results: In the first video we show the laparoscopic intervention of the liver metastasis. A tourniquet is placed for the Pringle manoeuvre in case it'd be needed. A minimal mobilization of the liver was performed exclusively sectioning the round and falciform ligaments. The operation is guided with indocyanine green administration 24 hours before. That makes us possible to identify the lesion and discard the presence of others lesions. A partial resection of segment 6 is performed. The specimen was removed from an enlargement of the midline 12mm port. The intervention is completed in 80 minutes, achieving a negative margin, with minimal blood loss and without the need to execute the Pringle manoeuvre. The postoperative evolution was correct, without complications and the patient was discharged after 4 post-operative days. After 10 months, a new hepatic lesion is observed in segment 7, suggestive of metastasis. Presenting a volume reduction of the lesion in response to chemotherapy, it was decided a new intervention. The second video shows the atypical resection on segment seven. No important post-chirurgical adhesions are found except for some at the midline level and at the level of the preceding liver resection that can be easily removed. A tourniquet is easily placed through the foramen of Winslow to realize the Pringle manoeuvre in case it'd be needed. The right liver is partially mobilized for an optimal view of the lesion. The operation can be easily performed in 110 minutes, given the limited presence of postoperative adhesions, having previously been operated by laparoscopy. The Pringle manoeuvre is performed for 15 minutes, with minimal blood loss. The postoperative evolution is correct, discharging the patient 4 days later. Conclusion: This video shows the advantages of laparoscopy in the treatment of colorectal liver metastases. The minimal adhesions with this approach, makes easier the reinterventions that this patients usually need with similar morbidity and faster recovery.