How to start laparoscopic major liver surgery

Abstract

Laparoscopic liver resection is becoming more frequently performed for primary or secondary liver tumors owing to the advancement of laparoscopy, instrumentations and maturation of laparoscopic surgical skills. As such, it is increasingly widely accepted by most centers as the standard approach for minor resections. The next phase of development in laparoscopic liver surgery is the generalization of technique to major liver resection. Knowledge on port positions and placements, haemostasis and parenchymal transection techniques are core elements for undertaking of a successful laparoscopic major liver resection. To become fully trained for laparoscopic major liver resections, one should have sufficient prior experience in performing open major hepatectomy in order to gain adequate anatomical knowledge on the caudal-cranial relationship between the liver and the inferior vena cava. Moreover, a visual understanding on the course of middle hepatic vein and its main V5 and V8 branches (as in the case of laparoscopic right hepatectomy) based on preoperative scans would help to reduce the chance of their inadvertent injury during parenchymal transection. The skills for laparoscopic major liver resection is more likely to become widely disseminated if the surgical steps in open hepatectomy could be readily reproduced in the laparoscopic settings. Hilar dissection for clear exposure and isolation of the ipsilateral hepatic artery and portal vein is therefore the preferred approach for control of inflow vessels. A reverse lithotomy position, pneumoperitoneum pressure kept at 14mmHg and fluid restriction all contribute to maintain a low venous pressure that would in turn facilitate parenchymal transection. Laparoscopic Cavitron ultrasonic surgical aspirator is the recommended choice of device for transection as it allows fine tissue transection with clear exposure, and then division of intraparenchymal branches of hepatic veins and bile ducts. Intraparenchymal encirclement and division of the ipsilateral bile duct would certainly help to widen the space between the two transection surfaces, and therefore facilitate further parenchymal transection. Finally, full isolation and encirclement of the ipsilateral major hepatic vein is mandatory for secure purchasing by vascular stapler before its division. As depth perception is of vital importance for a safe liver parenchymal transection, the use of 3-dimensional laparoscopy may enhance the surgeons’ performance as well as the dissemination of laparoscopic skills for major liver resection.