Page 17 - Laparoscopic Journal - WJOLS

WJOLS

Laparoscopic Liver Resection: Current Status and Techniques
ReLATive ConTRAindiCATionS sighting of the hilar structure and to position the small
To LApARoSCopy bowel in the lower abdomen and pelvis. Two to three
trocars are placed under direct visualization to facilitate
Although refractory hypotension is the only absolute triangulation of the intended surgery site. Here, laparos-
contraindication to laparoscopy, there are many situations copic ultrasound is of great use to determine the depth
that make its use ill advised. In general, patients with an of the mass and its juxtaposition to vasculature.
American Society of Anesthesiologists (ASA) classifica- Lesions on the liver surface may be wedged out with
tion of four or higher should not undergo laparoscopic the use of laparoscopic adaptations of the Harmonic
procedures because hemodynamic instability is likely scalpel (Ethicon EndoSurgery, Blue Ash, Ohio), LigaSure
to arise in the setting of a pneumoperitoneum. As such, (Covidien, Boulder, Colo), Enseal (Ethicon Endo-Surgery,
patients with poor cardiopulmonary reserve should Blue Ash, Ohio), or any other bipolar energy device.
temper the surgeon’s enthusiasm for laparoscopic pur- Generally, the hilum is dissected and the respective
suits. However, rarely is the surgeon confronted with hepatic artery ligated and divided. The portal vein to the
such obvious and straightforward clinical decisions. affected side is then clamped. Transection then begins
The assessment of the risks and benefits of alter- in the usual fashion, and major vasculature is controlled
native operative approaches underscores the relative with laparoscopic stapling devices. The major bile ducts
contraindications for laparoscopic liver resection. In our are also stapled, and the specimen is extirpated through
experience, patients who have had prior open foregut an extended umbilical incision. For this reason, it is more
surgery are generally poor candidates for a laparoscopic prudent to attempt larger resections with the alternative
approach, given the likely adhesive disease. Moreover, hand-assisted and hybrid techniques, given the similarity
bulky pathology or hepatomegaly usually predicates in the incision size.
open surgery, as hepatic mobilization can be problematic
(Box 1). In contrast, laparoscopic resection for malignancy hAnd-ASSiSTed TeChnique And
has been shown to be safe, which parallels the findings The hyBRid TeChnique
for treatment of other intra-abdominal organ cancers.
The incision that accommodates the hand port is the same
for the hand-assisted and the hybrid techniques, there are
opeRATive TeChniqueS
some definitive differences. Both operative procedures
Numerous methods of laparoscopic resection have employ the hand as a retractor, but hand-assisted liver
gained popularity with increased sharing and collabora- resection implies that the resection is performed entirely
tion in the surgical community. Recognizing the diversity intracorporeally. Conversely, the hybrid technique is
of these laparoscopic techniques used for liver resection, a practice of using the hand to mobilize the liver with
a panel of 45 well-known hepatobiliary surgeons worked subsequent removal of the hand port so as to perform
to establish a standard classification system and summa- the liver transection in an open fashion without exten-
rize a unified position statement on safety and efficacy ding the incision.
of laparoscopic liver resection. Many favors the hybrid approach as they intuitively
feel that this technique provides a more expeditious and
puRe LApARoSCopy practical manner for mobilization, parenchymal dissec-
tion, and removal of liver specimen. Here, I will describe
Pure laparoscopy is usually used for wedge resections the hybrid approach to liver resection, but the details are
of anterior lesions of the liver or masses located in the applicable to any system of laparoscopy using the hand.
12
left lateral segment, but it has been used for major lobe A 7.5 cm subxiphoid incision is made, and a hand port
resections as well. Access is gained into the abdomen, is inserted for hand assistance. A pneumoperitoneum
depending on the surgeon’s preference, and an umbilical is established after a standard Hassan trocar insertion
10 mm trocar is placed. After insufflation, the patient is periumbilically, and a 5 mm trocar is placed obliquely in
moved into the reverse Trendelenburg position to enable
the right or left subcostal margin depending on the loca-
tion of the target lobe. The periumbilical trocar placement
Box 1: Relative contraindications to laparoscopic hepatic resection
• ASA classification ≥ 4 can be particularly risky because of its larger size and the
• Poor cardiopulmonary reserve relatively blind nature of insertion. This possibility can
• Prior open foregut surgery be minimized by introducing the trocar using the Hassan
• Large (> 10 cm) posterior lesions cut-down technique.
• Hepatomegaly One hand should be placed into the abdomen through
ASA, American Society of Anesthesiologists the subxiphoid incision to receive the trocar as the other
World Journal of Laparoscopic Surgery, May-August 2015;8(2):48-51 49