Laparoscopic liver resection for posterosuperior tumors using caudal approach and postural changes: A new technical approach

Abstract

Laparoscopic liver resection (LLR) for tumors in the posterosuperior liver [segment (S) 7 and deep S6] is a challenging clinical procedure. This area is located in the bottom of the small subphrenic space (rib cage), with the large and heavy right liver on it when the patient is in the supine position. Thus, LLR of this area is technically demanding because of the handling of the right liver which is necessary to obtain a fine surgical view, secure hemostasis and conduct the resection so as to achieve an appropriate surgical margin in the cage. Handling of the right liver may be performed by the hand-assisted approach, robotic liver resection or by using spacers, such as a sterile glove pouch. In addition, the operative field of posterosuperior resection is in the deep bottom area of the subphrenic cage, with the liver S6 obstructing the laparoscopic caudal view of lesions. The use of intercostal ports facilitates the direct lateral approach into the cage and to the target area, with the combination of mobilization of the liver. Postural changes during the LLR procedure have also been reported to facilitate the LLR for this area, such as left lateral positioning for posterior sectionectomy and semi-prone positioning for tumors in the posterosuperior segments. In our hospital, LLR procedures for posterosuperior tumors are performed via the caudal approach with postural changes. The left lateral position is used for posterior sectionectomy and the semi-prone position is used for S7 segmentectomy and partial resections of S7 and deep S6 without combined intercostal ports insertion. Although the movement of instruments is restricted in the caudal approach, compared to the lateral approach, port placement in the para-vertebra area makes the manipulation feasible and stable, with minimum damage to the environment around the liver.

Laparoscopic liver resection: the current status and the future

“…It was recommended as a routine liver surgery by the 1 st international expert consensus on laparoscopic liver resection in 2008 (2). Procedures including isolated caudate lobectomy, trisegmentectomy and middle hepatic lobectomy (segments 4, 5, and 8) are rarely performed even in experienced institute for the technique difficult and the risk of massive bleeding (25,26). For the tumor located in segment VII and VIII, normal laparoscopic instruments are difficult to reach.…”

Multicentre analysis of the learning curve for laparoscopic liver resection of the posterosuperior segments

“…A minor bias of the study is the possible variation in patient and trocar positioning over time. Although the transabdominal supine position is the preferred position in the participating centres, the sporadic use of intercostal trocars and different patient positions could be considered. Technological improvements over the years, including energy instruments, preoperative anatomical reconstruction, three‐dimensional vision and augmented reality, will continue to improve training opportunities.…”

Laparoscopic resection of liver tumors

“…Anatomic liver resection for tumors located in postero-superior (segment 7, segment 8) segments and segment 4a are technically difficult because of difficulty of access and are associated with more blood loss, risk of conversion to open surgery or change to hemi-hepatectomy [18][19][20][21] . Strategies such as use of a spacer, left lateral position, intercostal ports, hand-assisted, robot-assisted or other approaches have demonstrated reduced blood loss and need for conversion in such tumors [18][19][20][21] .…”