Laparoscopic resection of hepatocellular carcinoma at segment 7: the posterior approach to anatomic resection

Abstract

Background Open anatomical liver resections remain one of the most effective treatments of hepatocellular carcinoma (HCC) and results in better recurrence-free and overall survival compared to nonanatomical resections [1]. On the other hand, laparoscopic hepatectomies for HCC have recently emerged with the benefits of reduced blood loss, shorter hospital stay, and less severe wound pain [2,3]. Classically, liver lesions considered suitable for laparoscopic resection were those small tumors (\4 cm) located over the anterior and left lateral segments [3]. However, we would like to expand the current indications and here we present our techniques of laparoscopic anatomical resection for a HCC that was located at right posteriosuperior segment 7. Methods Our patient was a 60-year-old gentleman who had Child's A hepatitis B cirrhosis and was on entecavir. During a follow-up CT scan, a 2.6-cm segment 7 lesion with early arterial enhancement and contrast washout was noted and was subsequently confirmed with arteriogram. a-Fetoprotein was 3 ng/ml (normal \ 20 ng/ml). The video demonstrates a posterior approach to laparoscopic resection of segment 7. Results Operative time was 510 min. Blood loss was 800 ml and no perioperative transfusion was required. Postoperative recovery was uneventful and only simple oral analgesics were required for pain control. He was discharged on postoperative day 6. Histology showed a moderately differentiated hepatocellular carcinoma and all resection margins were clear. Subsequent follow-up CT scan 6 months after the operation showed no evidence of recurrence and a-fetoprotein level was normal. Conclusions Laparoscopic hepatectomy for HCC over the right posterior segment of the liver is feasible in selected patients with favorable results in terms of wound size, postoperative recovery, and hospital stay. Maximal liver conservation was achieved in performing oncologic anatomical resection of segment 7 instead of a posterior sectionectomy. On the other hand, a posterior approach was recommended because it allowed early intrahepatic control of pedicles and identification of the right hepatic vein to guide parenchymal transection along the intersegmental plane.

Accuracy of actual resected liver volume in anatomical liver resections guided by 3‐dimensional parenchymal staining using fusion indocyanine green fluorescence imaging

“…However, these conventional methods have some limitations. First, these techniques do not provide clear, valid and persistent demarcation lines, and always fail in segmental staining . Secondly, since the direction of parenchymal dissection is dependent on the surgeon’s interpretation of the demarcation using landmark vessels, it is often difficult to guarantee the accuracy of the intersegmental plane.…”

Caudal approach to pure laparoscopic posterior sectionectomy under the laparoscopy-specific view

“…The operation time of this case was 341 min including the dissection of adhesion after open colorectal surgery and short and mid-term prognosis; an acceptable time for such a procedure. Although, the operative blood loss of 1356 mL is larger than some cases [16,20,21,23,24] , the total exposure of right hepatic vein main trunk may have influenced this in part, and this number should be decreased in the future with more experience. In conclusion, this new procedure, "caudal approach pure laparoscopic posterior sectionectomy with parenchymal transaction prior to mobilization of the liver under the laparoscopy-specific view", is feasible and useful for patients with tumors close to the RHV and when exposure of the RHV is necessary.…”

“…Although Cheng et al [24] reported performing a posterior approach to laparoscopic anatomic resection hepatocellular carcinoma at segment seven; they also described the traditional mobilization of the right liver. We had experienced the challenge of exposing the cutting plane in pure laparoscopic posterior sectionectomy due to the direction of cutting plane, especially when exposure of the right hepatic vein was necessary.…”

Surgical outcomes after laparoscopic or robotic liver resection in hepatocellular carcinoma: a propensity‐score matched analysis with conventional open liver resection

“…Currently, laparoscopic liver resection is a standard procedure for patients with a single tumor of less than 5 cm, restricted to the left lateral segment or a subcapsular lesion in the right anteroinferior segment, although some experts have reported the feasibility of laparoscopic major liver resection .…”