Color Atlas of Laparoscopic Liver Resection 9789811615450, 9811615454

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Ho-Seong Han Jai Young Cho

Color Atlas of Laparoscopic Liver Resection

Color Atlas of Laparoscopic Liver Resection

Ho-Seong Han • Jai Young Cho

Color Atlas of Laparoscopic Liver Resection

Ho-Seong Han Seoul National University Bundang Hospital Seoul National University College of Medicine Department of Surgery Seoul, Korea (Republic of)

Jai Young Cho Seoul National University Bundang Hospital Seoul National University College of Medicine Department of Surgery Seoul, Korea (Republic of)

ISBN 978-981-16-1545-0    ISBN 978-981-16-1546-7 (eBook) https://doi.org/10.1007/978-981-16-1546-7 © Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Preface

The introduction of laparoscopic surgery can be one of the most dramatic changes in the history of the surgery. This surgery has benefitted the patients with less pain, rapid recovery, and better cosmesis. However, laparoscopic liver surgery is the latest to be developed due to its steep learning curve. In spite of a few decades of history, it is still not easy to perform major liver resection and parenchymal transection in superior posterior lesions. And there is still a risk of massive bleeding, which may lead to fatal conditions. Therefore, the operative technique in laparoscopic liver surgery is very important to all surgeons involved in liver surgery. The first and second international consensus conferences have initiated big surges in this field. Many liver surgeons have got interested in this surgery. Reports on the surgery have sharply increased. And the laparoscopic left lateral sectionectomy and minor resection have become a standard procedure. However, there has also been caution that we should be careful when performing major liver resection. The International Laparoscopic Liver Society was established to standardize the surgery and propagation of the techniques. Although there has been rapid development in this surgery, we still have to go a long way to reach our goal. In our center, we have tried to show that this surgery can be performed safely and meticulously. In this regard, we have reported all types of laparoscopic anatomic surgery with video clips in various journals. The contents of this atlas are a collection of our previous reports on operative procedures and videos. For a better understanding of operative procedures, each content is linked with video clips. Some videos were edited a long time ago, and the quality of images may not be satisfactory. I hope that we can provide better quality video in the future. For this atlas, my coauthor Dr. Jai Young Cho has dedicated a lot. He has designed and filled up all the contents with his passion and energy. Without him, this atlas cannot be possible. My international fellows, Dr. Mizelle D’Silva, Dr. Kovid Nepal, Dr. Mosteanu Benone-Iulian, Dr. Yelran Taupyk, and Dr. Mohamed Rabie, have contributed a lot in completing this atlas when they are working with me. My junior colleague Dr. Boram Lee has helped in final editing. And I sincerely appreciate my colleagues, Dr. YoungRok Choi, Dr. Yoo-Seok Yoon, Dr. Hae Won Lee, and Dr. Jun Suh Lee, for their persistent support. During the preparation of this atlas, I have got immense help and support from my colleagues and friends all over the world. I am so blessed that I have them. I hope that this atlas will help many liver surgeons in their pursuit of better surgery. Seoul, Korea (Republic of) June 17, 2021

Ho-Seong Han

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Contents

Introduction���������������������������������������������������������������������������������������������������������������������������  1 Part I Basic Skills Patient Positioning and Trocar Placement�������������������������������������������������������������������������  7 Bleeding Control�������������������������������������������������������������������������������������������������������������������  9 Glissonean Approach versus Individual Ligation ������������������������������������������������������������� 11 Application of Indocyanine Green (ICG)��������������������������������������������������������������������������� 13 Part II Specific Liver Resection Left Lateral Sectionectomy ������������������������������������������������������������������������������������������������� 17 Anatomical Liver Resection in Segments 2 or 3����������������������������������������������������������������� 21 Anatomical Liver Resection in Segment 4 ������������������������������������������������������������������������� 25 Left Hepatectomy����������������������������������������������������������������������������������������������������������������� 27 Right Hepatectomy��������������������������������������������������������������������������������������������������������������� 31 Right Posterior Sectionectomy��������������������������������������������������������������������������������������������� 35 Anatomical Liver Resection in Segments 5 or 8����������������������������������������������������������������� 39 Right Anterior Sectionectomy��������������������������������������������������������������������������������������������� 45 Anatomical Liver Resection in Segments 6 or 7����������������������������������������������������������������� 49 Central Bisectionectomy������������������������������������������������������������������������������������������������������� 55 Caudate Lobectomy ������������������������������������������������������������������������������������������������������������� 59 Hepatic Cyst Unroofing ������������������������������������������������������������������������������������������������������� 63 Donor Right Hepatectomy��������������������������������������������������������������������������������������������������� 65

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Introduction

Over the past 30 years, laparoscopy has emerged into the latest trend in surgery proving to be safe and effective treatment method, possibly superior to the traditional open surgery. With advancement comes adoption of new technology and training in new techniques. Laparoscopy has advanced from laparoscopic appendectomy and cholecystectomy to bariatric surgery, fundoplication, nephrectomy, colonic anterior resection, and finally up to liver surgery. However, it is interesting to note that though laparoscopic liver surgery is gaining ground in the twenty-first century the first laparoscopic liver resection (LLR) was performed way back in 1991, LLR is gaining ground three decades later. Since liver surgery is technically challenging operation, LLR was considered as an unsafe procedure because of fear of compromising oncological safety and difficulties of the procedure. Therefore, early indication of LLR used to be excision of small benign tumors. In 1996, Dr. Azagra and Dr. Kaneko reported the first series of laparoscopic anatomical resection, particularly left lateral sectionectomy. First hemihepatectomy was reported in 1997 by Huscher et al. The first case of laparoscopic right posterior sectionectomy was reported in 2006 from our center. With dramatic development of surgical techniques and laparoscopic equipment, difficult procedures such as hemihepatectomy, right posterior sectionectomy, caudate lobe resection are being performed laparoscopically. Laparoscopic surgeons have now ventured into the field of liver transplant with even donor hepatectomy. One of the biggest accomplishments in laparoscopic liver surgery was organizing the International Consensus Conference on Laparoscopic Liver Resection (ICCLLR). The First ICCLLR was convened on 7th–8th November 2008  in Louisville, Kentucky, USA. Forty five experts of open and laparoscopic liver surgery were in attendance.

As LLR is a new emerging technique there is no level 1 evidence available due to lack of adequate RCTs. Hence committee discussed the safety of the procedure based on existing literatures, although there are few available RCTs. Acceptable indications for LLR were to be 1. Solitary lesions, 5  cm or less, located in liver segments 2–6 2. Left lateral sectionectomy Liver resections were divided into two categories: major and minor. Minor resection is the category in which two or fewer Couinaud segments are removed. Major resection to the one in which three or more segments are removed. Operation difficulties level is not considered when categorizing major and minor resection. Left lateral sectionectomies, or resections of segments 2, 3, 4b, 5, and 6 will be naturally categorized as minor resection. Even resection on posterior superior segments will be considered as minor resection. After the first ICCLLR, the propagation of the LLR has been more increased. Many surgeons and centers have interest in performing LLR. Laparoscopic left lateral and left hemihepatectomy have become popular procedures, with increasing number of institutes performing major resection. The second International Consensus Conference on Laparoscopic Liver Resection (ICCLLR) was held on 4th– 6th October 2014, in Morioka, Japan. During this consensus, a jury of expert hepatobiliary surgeons from different countries was called upon to better define the current role of LLR and to develop internationally acceptable recommendations. 17 questions were discussed in terms of value, technique, and short-term outcomes. The most important message from the ICCLLR was to protect patients from this new surgical procedure. The ICCLLR recommended

© Springer Nature Singapore Pte Ltd. 2021 H.-S. Han, J. Y. Cho, Color Atlas of Laparoscopic Liver Resection, https://doi.org/10.1007/978-981-16-1546-7_1

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Introduction

caution for major resection due to novelty of this new surgical procedure: For online prospective registry, the operator of LLR is requested to fill up simple items at four time points, i.e. preoperation, after-operation, after discharge, and readmission if it happens. The system incudes items to calculate the difficulty score so that the operator can recognize the difficulty of planned LLR preoperatively. The expert panel proposed criteria (IWATE criteria), which is determined by tumor location, tumor size, proximity of major vessels, extent of liver resection, HALS/Hybrid and liver function. The summed up score can be used to predict the difficulties of LLR (Fig. 1). Han et al. reported a simple-to-use recommendation score based on the current indication for LLR, from the perspec-

tive of surgeons at a high-volume center (Fig. 2). This recommendation panel was devised based on the tumor location and type of resection. The highest level of difficulty is given a score of 7 points, according to this scoring system. Five other elements are considered together with that factor to determine the final score; tumor size, tumor number, tumorvessel relationships, liver function and previous surgery (Fig. 3). Finally, the highest possible score is 12. LLR procedure are categorized into four classes (Fig. 4). The first category is ‘Strongly Recommended’ LLR, in which the patient would probably benefit most from a minimally invasive approach: small tumor, located in an anterior segment, removed in a nonanatomic fashion (score 1–2). The second category is ‘Recommended’ LLR, for which the conditions require nonanatomic resection or anatomic resection without

Difficulty scoring system Difficulty index

0

2

1

4

5

6

7

Intermediate

Low

Difficulty level

3

8

9

10

11

Advanced

12

Expert

Right or left hepatectomy

Left lateral sectionectomy Index surgery Simple and small partial hepatectomy in segment III

Posterior sectionectomy for segment VII tumor > _ 3 cm

Scoring system Tumor size

Tumor location (Couinaud segment)

VIII 5

IVa

2

4

1 III

IVb 3 VII 5

Segment

II

V 3 I VI

4

2

S1 S2 S3 S4a S4b S5 S6 S7 S8

Score

_3 cm

4 2 1 4 3 3 2 5 5

Score 0 1

Proximity to major vessel* No Yes

Score 0 1

*Main or second branch of Glisson’s tree, major hepatic vein, or inferior vena cava HALS/Hybrid

Extent of liver resection

Liver function

Score Partial resection

0

Left lateral sectionectomy

2

Segmentectomy

3

Sectionectomy and more

4

Fig. 1  Difficulty scoring system from HBSN 2016

Score

Score

No

0

Child Pugh A

0

Yes

–1

Child Pugh B

1

Introduction

3 Easy

Moderate

Difficult

Very difficult

Resection extent

Point

1

2

3

4

NonAnatomical resection

0

S3, S4B, S5 NAR

S2, S4A, S6 NAR

S1C1, S7, S8 NAR

S1Pc NAR

Anatomical resection

1

S2, 3, 5, S6 AR

S4 AR

S1, S7, S8 AR

Major resection

2

LH

RH

Ext. LH Ext. RH

Complicated resection

3

RAS RPS

CBS

LLS

S: Segment; NAR: non-anatomical resection; LLS: left lateral sectionectomy; C1: caudate lobe; Pc: paracaval; AR: anatomical resection; LH: Left Hepatectomy; RH: Right Hepatectomy; Ext.: extended; RAS: right anterior sectionectmy; RPS: right posterior sectionectomy; CBS: central bisectionectomy.

Fig. 2  The grade of difficulty

Tumor number >2

+1

Cirrhosis

+1

Tumor size >3cm

+1

Tumor in contact or invading major vessel

+1

Previous abdominal surgery

+1

Fig. 3  The factors which affect the difficulty to the operation

Fig. 4  Recommendation levels of Laparoscopic liver resection

associated risk factors, such as cirrhotic liver or previous abdominal surgery. We believe these patients will still benefit from a minimally invasive approach, and most surgeries can be successfully completed with this approach (score 3–4). The third category is ‘Weakly Recommended’ LLR, including tumors of >3 cm in diameter, located deeply, or in contact with major vessels. These cases should not be routinely treated with a laparoscopic approach, and an expert surgeon is required (score 5–6). The fourth category is ‘Very Weakly Recommended’, which includes patients with multiple risk factors. In such cases, the minimally invasive approach should only be performed exceptionally, by very experienced surgeons (score > 7). It is necessary to focus on training surgeons in laparoscopic skills especially for major hepatectomy, due to steep learning curve required. A formal structure of education needs to be created. According to a study published by Villeni et al., the learning curve for LLR follows an uneven pattern with alternate periods of improvement and regression till the surgeon reaches a plateau from where no further improvement is possible. The periods of regression are probably due to overconfidence once a stage of improvement has been reached. Hence the surgeon needs to be vigilant during the entire training process till the plateau phase has been reached. 1. Caudal approach rather than anterior approach. It gives improved exposure of the IVC and helps in identification of Laennec’s capsule and Glissonian pedicle at the hilar plate. Caudal-cranial transection of liver parenchyma helps in better identification of intraparenchymal structures along with added magnification. 2. CO2 pneumoperitoneum helps in reducing bleeding from hepatic veins. Decreasing air pressure by temporary stoppage of artificial ventilation helps to reduce backbleeding. 3. Trendelenberg position helps decrease venous pressure and improves exposure by using gravity. 4. Left Interal decubitus position offers better exposure of the right posterior segments and lifts right hepatic vein higher than IVC so as to reduce hepatic venous bleeding. International meeting on donor hepatectomy was held during the 26th World Congress of the International Association of Surgeons, Gastroenterologists and Oncologists (IASGO) in Seoul, South Korea in 2016. The expert panel discussed on laparoscopic living donor hepatectomy and concluded the role of laparoscopic donor hepatectomy will increase in both adult and pediatric age group. The first laparoscopic Donor right hepatectomy was performed in early 2010 by our center.

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Another area of discussion was cirrhotic patients. LLR was found to have increasing advantages for cirrhotic patients with a lower incidence of post-operative liver failure and ascites due to less liver manipulation and preservation of abdominal musculature with smaller incisions. International Laparoscopic Liver Society (ILLS) was officially launched at the IHPBA meeting in Sao Paulo in April 2016. The first meeting was held in Paris in 2016 and decided to hold meeting biannually. Although, LLR has a rapid growth in the last several years, the surgery is still limited to high volume centers with experienced surgeons. The next challenge of LLR is standardization of the procedures and systematic training of young surgeons. Training in both hepatobiliary surgery and laparoscopic surgery is needed in order to master the technique of LLR.

Suggested Readings Buell JF, Cherqui D, Geller DA, O’Rourke N, Iannitti D, Dagher I, et al. The international position on laparoscopic liver surgery: the Louisville statement, 2008. Ann Surg. 2009;250(5):825–30.

Introduction Cho JY, Han HS, Wakabayashi G, Soubrane O, Geller D, O’Rourke N, Buell J, Cherqui D. Practical guidelines for performing laparoscopic liver resection based on the second international laparoscopic liver consensus conference. Surg Oncol. 2018;27:A5–9. Han HS, Cho JY, Kaneko H, Wakabayashi G, Okajima H, Uemoto S, et al. Expert panel statement on laparoscopic living donor hepatectomy. Dig Surg. 2018;35(4):284–8. Kaneko H, Takagi S, Shiba T.  Laparoscopic partial hepatectomy and left lateral segmentectomy: technique and results of a clinical series. Surgery. 1996;120:468–75. Shehta A, Han HS, Yoon YS, Cho JY, Choi Y. Laparoscopic liver resection for hepatocellular carcinoma in cirrhotic patients: 10-year single-­center experience. Surg Endosc. 2016;30:638–48. Wakabayashi G. What has changed after the Morioka consensus conference 2014 on laparoscopic liver resection? Hepatobiliary Surg Nutr. 2016;5(4):281–9. Yoon YS, Han HS, Choi YS, Jang JY, Suh KS, Kim SW, et al. Total laparoscopic right posterior sectionectomy for hepatocellular carcinoma. J Laparoendosc Adv Surg Tech A. 2006;16(3):274. Mosteanu BI, Han HS, Cho JY, Lee B. When should we choose a laparoscopic approach? A high-volume center recommendation score. Surg Oncol. 2020;34:208−211. https://doi.org/10.1016/j.suronc.2020.04.024. Epub 2020 May 4.

Part I Basic Skills

Patient Positioning and Trocar Placement

The patient can be placed in a supine position with the surgeon standing on one side (or a left semi-decubitus position if the liver lesion is in the right side), or the patient can be placed in a lithotomy position with the surgeon standing between the legs of the patient. After pneumoperitoneum is achieved through an umbilical incision, the laparoscope is inserted. For operative manipulation in partial hepatectomy, three or four trocars are placed in a concentric circle radiating from the tumor. Care must be taken to avoid injuring vessels during port insertion, particularly in cirrhotic patients who tend to have thrombocytopenia, recannulated umbilical veins, or large collateral veins that develop in the anterior abdominal wall. In left lateral sectionectomy, three trocars are placed at the right hypochondrium and bilateral abdomen. For anatomical hepatectomies other than left lateral sectionectomy, four trocars are usually necessary at the epigastrium, right hypochondrium, and bilateral abdomen. Intercostal trocars

are useful for instrument manipulation during resection of the superior and posterior region of the liver. A 5-mm trocar is placed for Pringle maneuver when it is needed.

Suggested Readings Chai S, Zhao J, Zhang Y, et al. Arantius ligament suspension: a novel technique for retraction of the left lateral lobe liver during laparoscopic isolated caudate lobectomy. J Laparoendosc Adv Surg Tech A. 2018;28:740–4. Harada N, Maeda T, Yoshizumi T, et al. Laparoscopic liver resection is a feasible treatment for patients with hepatocellular carcinoma and portal hypertension. Anticancer Res. 2016;36:3489–97. Hsu KF, Liu TP, Yu JC, et al. Application of marionette technique for 3-port laparoscopic liver resection. Surg Laparosc Endosc Percutan Tech. 2012;22:e186–9. Inoue Y, Suzuki Y, Fujii K. Laparoscopic liver resection using the lateral approach from intercostal ports in segments VI, VII, and VIII. J Gastrointest Surg. 2017;21:2135–43.

© Springer Nature Singapore Pte Ltd. 2021 H.-S. Han, J. Y. Cho, Color Atlas of Laparoscopic Liver Resection, https://doi.org/10.1007/978-981-16-1546-7_2

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Bleeding Control

Laparoscopic liver resection (LLR) is becoming an attractive treatment modality for liver disease including hepatocellular carcinoma (HCC). Despite the established advantages of laparoscopy, bleeding control during laparoscopic liver resection has been considered difficult. However, there are several methods that LLR will be performed with minimal blood loss as possible. Pneumoperitoneum and Central venous pressure (CVP) • Pneumoperitoneum (10–14 mmHg) allows a good control of bleeding and low CVP (inferior to 5  mmHg) can decrease blood loss. Imaging magnification • Recent development of flexible endoscopy and high definition imaging is helpful in providing optimal operative views. These developments provided a precise vascular dissection and facilitate the control of pedicles. Transection devices and Stapling devices • Various kinds of devices for parenchymal transection have been helpful for advanced technique. –– Ultrasonic shears: Harmonic scalpel (cutting and coagulation) –– Vessel sealing system: Enseal, LigaSure –– Cavitron ultrasonic surgical aspirator (CUSA) (fragmentation, irrigation, aspiration). • Application of stapling devices in LLR allows a ligation and dissection of inflow and outflow vessels of the liver. –– Echelon/Echelon Flex (45 mm, 60 mm) –– Endo GIA Ultra Universal Inflow control • Inflow control will be helpful in minimizing blood loss during parenchymal transection. Preparation to prevent unexpected hemorrhage, particularly in liver cirrhosis, is the key, as is prompt hemostatic technique.

–– Pringle maneuver (Portal triad clamping): Traditional method and most frequently used in the early stage of LLR.  The use of a vessel tape tourniquet or vessel clamp, intra- or extra-corporeally. –– Selective control of vascular inflow: Selective clamping causes no ischemic injury in the remnant liver and may be particularly useful in laparoscopy because of the longer duration of parenchymal transection. In order to minimize bleeding, basic technique such as gauze compression, intracorporeal suture techniques are pre-­ requisite for surgeons.

Suggested Readings Aldrighetti L, Guzzetti E, Pulitano C, Cipriani F, Catena M, Paganelli M, et  al. Case-matched analysis of totally laparoscopic versus open liver resection for HCC: short and middle term results. J Surg Oncol. 2010;102:82–6. Belli G, Cioffi L, Fantini C, D’Agostino A, Russo G, Limongelli P, et  al. Laparoscopic redo surgery for recurrent hepatocellular carcinoma in cirrhotic patients: feasibility, safety, and results. Surg Endosc. 2009;23:1807–11. Chao YJ, Wang CJ, Shan YS. Technical notes: a self-designed, simple, secure, and safe six-loop intracorporeal Pringle’s maneuver for laparoscopic liver resection. Surg Endosc. 2012;26:2681–6. Cho A, Yamamoto H, Nagata M, Takiguchi N, Shimada H, Kainuma O, et al. Safe and feasible inflow occlusion in laparoscopic liver resection. Surg Endosc. 2009;23:906–8. Costi R, Scatton O, Haddad L, Randone B, Andraus W, Massault PP, et  al. Lessons learned from the first 100 laparoscopic liver resections: not delaying conversion may allow reduced blood loss and operative time. J Laparoendosc Adv Surg Tech A. 2012;22:425–31. Gayet B, Cavaliere D, Vibert E, Perniceni T, Levard H, Denet C, et al. Totally laparoscopic right hepatectomy. Am J Surg. 2007;194:685–9. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-­ Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924–6.

© Springer Nature Singapore Pte Ltd. 2021 H.-S. Han, J. Y. Cho, Color Atlas of Laparoscopic Liver Resection, https://doi.org/10.1007/978-981-16-1546-7_3

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10 Ker CG, Chen JS, Kuo KK, Chuang SC, Wang SJ, Chang WC, et al. Liver surgery for hepatocellular carcinoma: laparoscopic versus open approach. Int J Hepatol. 2011;2011:596792. Lee KF, Cheung YS, Chong CN, Tsang YY, Ng WW, Ling E, et  al. Laparoscopic versus open hepatectomy for liver tumours: a case control study. Hong Kong Medical Journal. 2007;13:442–8.

Bleeding Control Tranchart H, Di Giuro G, Lainas P, Roudie J, Agostini H, Franco D, et  al. Laparoscopic resection for hepatocellular carcinoma: a matched-pair comparative study. Surg Endosc. 2010;24:1170–6.

Glissonean Approach versus Individual Ligation

Usually, for a right hemihepatectomy or a right posterior sectionectomy, the liver was fully mobilized from the inferior vena cava as much as possible and multiple small hepatic veins were clipped and divided. However, for left hemihepatectomy, we do not mobilize the liver as the first step. When the Glissonian approach was adopted for right sided resection, hilar dissection was performed to isolate the right Glisson’s pedicles at the inferior surface of the quadrate lobe. To isolate and tape the right pedicle, long right angle type clamp or Goldfinger™ was valuable. After taping right pedicle, the whole pedicle can be ligated en masse by Endo stapler. For Glissonian approach for right posterior sectionectomy, liver parenchymal dissection between right anterior and posterior Glisson pedicles using CUSA is required to isolate right posterior sectional branch. After taping right posterior pedicle, the whole pedicle can be ligated by Endo stapler (Fig.  1). During this procedure, caution is required not to injure the anterior pedicle. When the posterior pedicle is small, it can be ligated by extra-large (12 mm) Hem-o-lock

clips. When right posterior pedicle is too short or difficult to isolate, laparoscopic bulldog clamp can be applied until after finishing parenchymal transection. Glissonian approach is common method to control inflow; however, individual ligation was also used especially in patients with IHD stone or in laparoscopic donor right hepatectomy. For individual ligation for right posterior sectionectomy, meticulous dissection of right hepatic artery was performed. Dissection proceeded to proximal part until bifurcation of right anterior and posterior hepatic artery was seen. The right posterior hepatic artery was ligated by small clips. Retracting bile duct upward and laterally, portal vein could be visible. Fine dissection was performed to identify the bifurcation of right posterior and anterior portal vein. Right posterior portal vein is also ligated using small clips. Bile duct resection was usually performed after parenchymal dissection to achieve clear anatomy of bile duct. Using Glissonian approach, laparoscopic anterior sectionectomy, central bisectionectomy, and anatomical 4, 5, 6 segmentectomy were also possible, respectively.

RAG

RPG RAG

RPG

Fig. 1  Glissonian approach to perform laparoscopic right posterior sectionectomy. RP right posterior Glisson, RAG right anterior Glisson © Springer Nature Singapore Pte Ltd. 2021 H.-S. Han, J. Y. Cho, Color Atlas of Laparoscopic Liver Resection, https://doi.org/10.1007/978-981-16-1546-7_4

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For central bisectionectomy, the Glisson’s pedicles to the left medial section were transected first and ischemic area of S4 was resected, then S4 was lifted to right side and dissection follow along the superior side of the hilar plate toward the right, the Glissonian pedicle to the right anterior section was transected. For S5 segmentectomy, the Glissonian pedicle to S5 was isolated after dissection along the right anterior pedicle.

Suggested Readings Ahn KS, Han HS, Yoon YS, Cho JY. Laparoscopic anatomic S4 segmentectomy for hepatocellular carcinoma. Surg Laparosc Endosc Percutan Tech. 2011;21(4):e183–6. Ahn KS, Han HS, Yoon YS, Cho JY, Kim JH. Laparoscopic anatomical S5 segmentectomy by the Glissonian approach. J Laparoendosc Adv Surg Tech A. 2011;21(4):345–8. Cho JY, Han HS, Yoon YS, Shin SH. Feasibility of laparoscopic liver resection for tumors located in the posterosuperior segments of the

Glissonean Approach versus Individual Ligation liver, with a special reference to overcoming current limitations on tumor location. Surgery. 2008;144(1):32–8. Cho JY, Han HS, Yoon YS, Shin SH. Outcomes of laparoscopic liver resection for lesions located in the right side of the liver. Arch Surg. 2009;144(1):25–9. Choi Y, Han HS, Sultan AM, Yoon YS, Cho JY. Glissonean pedicle approach in laparoscopic anatomical liver resection. Hepatogastroenterology. 2014;61(136):2317−20. Han HS, Cho JY, Yoon YS.  Techniques for performing laparoscopic liver resection in various hepatic locations. J Hepatobiliary Pancreat Surg. 2009;16(4):427–32. Han HS, Yoon YS, Cho JY, Ahn KS.  Laparoscopic right hemihepatectomy for hepatocellular carcinoma. Ann Surg Oncol. 2010;17(8):2090–1. Hwang DW, Han HS, Yoon YS, Cho JY, Kim JH, Kwon Y. Totally anatomic laparoscopic right anterior sectionectomy. J Laparoendosc Adv Surg Tech A. 2012;22(9):913–6. https://doi.org/10.1089/ lap.2012.0196. Yoon YS, Han HS, Cho JY, Ahn KS. Totally laparoscopic central bisectionectomy for hepatocellular carcinoma. J Laparoendosc Adv Surg Tech A. 2009;19(5):653–6.

Application of Indocyanine Green (ICG)

Fluorescence imaging technique using indocyanine green (ICG) has been developed, and well used to define anatomic structures and define segments to be resected. • Fluorescence liver mapping ICG is injected intravenously, after which it binds to plasma proteins and remains in the vascular space until selective uptake by the liver and excretion into the bile. Its unique catabolic character makes ICG particularly suitable for visualizing anatomical structures in the liver. Therefore, ICG can be used for anatomic landmark for resection. • Fluorescence cholangiography ICG also can be used to identify structures of biliary system. It may help for guiding transection of bile duct in donor surgery. Fluorescent images of the biliary tract can be obtained by intrabiliary and intravenous injection of ICG. For intrabiliary injection, the fluorescence intensity of protein-bound ICG was found to correlate with its concentration.  Thus, to obtain clear fluorescence images of the bile ducts diluted ICG solution should be used for imaging. It is also important to aspirate a small amount of bile into the syringe before injection to promote binding of ICG to proteins. Intrahepatic bile duct anatomy and the extrahepatic biliary system can be identified. • Fluorescence imaging of hepatic tumors The fluorescence pattern in hepatic tumors could be classified into three types: total fluorescence, in which all tumor tissue showed uniform fluorescence; partial fluo-

rescence, in which some tumor tissues showed fluorescence; and rim fluorescence, in which the cancer tissues were negative for fluorescence, but the surrounding liver parenchyma showed fluorescence. These fluorescence patterns were closely associated with the characteristics of the liver cancers. Total fluorescence-type tumors included all well-differentiated hepatocellular carcinoma (HCC)s, whereas rim fluorescence type tumors consisted only of poorly differentiated HCCs and colorectal liver metastasis (CRLM). The intraoperative ICG-fluorescence imaging of hepatic tumors is simple and is especially useful for identifying subcapsular lesions for removal during laparoscopic hepatectomy, in which visual inspection and palpation are limited compared with open surgery.

Suggested Readings Mitsuhashi N, Kimura F, Shimizu H, Imamaki M, Yoshidome H, Ohtsuka M, et al. Usefulness of intraoperative fluorescence imaging to evaluate local anatomy in hepatobiliary surgery. J HepatoBiliary-Pancreat Surg. 2008;15:508–14. Rosenthal EL, Warram JM, de Boer E, Basilion JP, Biel MA, Bogyo M, et al. Successful translation of fluorescence navigation during oncologic surgery: a consensus report. J Nucl Med. 2016;57(1):144–50. Terasawa M, Ishizawa T, Mise Y, Inoue Y, Ito H, Takahashi Y, et al. Applications of fusion-fluorescence imaging using indocyanine green in laparoscopic hepatectomy. Surg Endosc. 2017;31:5111–8.

© Springer Nature Singapore Pte Ltd. 2021 H.-S. Han, J. Y. Cho, Color Atlas of Laparoscopic Liver Resection, https://doi.org/10.1007/978-981-16-1546-7_5

13

Part II Specific Liver Resection

Left Lateral Sectionectomy

Indication

 atient Position and Trocar Placement P and Position of the Operator • Hepatocellular carcinoma: In such patient must have ade- and the Assistants (Fig. 1)

•

• • •

•

quate hepatic reserve and there is no severe portal hypertension. The tumor must be away from hepatic vein and left portal vein and not infiltrate it with no thrombosis. Metastases (colorectal metastasis): For metastatic liver tumors from colorectal cancer, a liver resection was indicated when there was no evidence of extrahepatic disease. A simultaneous laparoscopic resection of metastatic liver tumor and a colorectal carcinoma was also a good indication of whether a curative resection was possible. Intrahepatic cholangiocarcinoma away from main left duct and portal vein. Mucinous carcinoma. The indications of surgery for benign liver tumors included the presence of symptoms, danger of rupture, and uncertainity of diagnosis, suspicious of hepatic cyst with mural nodules, an intracystic septum or a honeycomb appearance which considered malignant features (Hemangioma, adenoma, focal nodular hyperplasia, liver abscess, cystadenoma, hydatid cyst, simple cyst). Intrahepatic lithiasis associated with intrahepatic duct stricture, atrophy of the diseased liver parenchyma, or both. Anatomic liver resection and intraoperative choledochoscopic exploration of an intrahepatic duct of the remnant liver were performed.

• The patient was intubated under general anesthesia and placed in a supine, 30° reverse Trendelenburg position, or placed in the French position (i.e., supine with the legs parted). The body was at a 30° head-up and feet-down tilt, with the left waist elevated 30° on soft cushion pads. • Five trocars (one 5 mm, two 10 mm, and two 12 mm trocars) were inserted in the upper abdominal Quadrant. After first 10 mm trocar was inserted through umbilicus, a pneumoperitoneum was established and maintained at