Page 18 - Laparoscopic Journal - WJOLS

Sasidhar Reddy
is used to gently advance the port-system through the Ligate and divide the right hepatic artery and dissect
fascia. After safe insufflation of the abdomen, the opera- posteriorly to delineate the portal vein. The right
tion begins with mobilization of the liver after positioning portal vein is circumferentially mobilized superiorly
the patient in reverse Trendelenburg. and divided. This devascularizes the right lobe inflow
Laparoscopic diathermic energy-based devices are and results in demarcation of the liver. The right hepatic
used to divide the visceral attachments and triangular and vein is then identified on the superior aspect of the liver
coronary ligaments. The side of hepatic pathology dictates and is divided using an articulating laparoscopic stapling
right or left hand insertion for hepatic lobe retraction. device (EndoPath ETS, Ethicon Endo-Surgery, Blue Ash,
The hand is an optimal retractor because of its ability Ohio) to ensure safe control of this very large vessel off
to conform to the contours of the liver and displace pres- of the inferior vena cava.
sure to the entire organ, preventing possible paren- Using the aforementioned hanging maneuver, pro-
chymal injury. Hand assistance also promotes safety ceed with liver division, being mindful to stay to the
in affording the surgeon with an expedient method right of the middle hepatic vein. We opt to ligate the right

of manual control of hemorrhage during a potential hepatic duct during intraparenchymal division because
vascular mishap. contralateral bile duct ischemia can occur if extrahepatic
Once the target liver lobe has been mobilized by dissection is attempted. The specimen is then removed
division of all peritoneal reflections, the abdomen is exsuf- through this incision.
flated and the hand port is removed. Because exposure
is of paramount importance, use of a retractor system is LefT hepATeCTomy uSing
recommended. With adequate and uncompromised retrac- The hyBRid TeChnique
tion, extrahepatic hilar vasculature ligation and division A left hepatectomy using the hybrid technique follows
then ensue to lessen blood loss during liver transection. many of the same steps that were previously discussed.
Next, the parenchymal dissection through the hard
port incision is accomplished with the aid of ultrasono- Again, one should be mindful of arterial variances, espe-
graphy and ultrasonic surgical aspirators (CUSA, Integra cially a replaced left hepatic artery coming from the left
LifeSciences Corp, Plainsboro, NJ) to identify the venous gastric artery. After correct identification and division
entities. During cases of major resection, the hanging of the middle and left hepatic arteries, dissection of the
maneuver as described by Dr Belghiti is used, with an left portal vein begins by working posteriorly to the
umbilical tape passed anterior to the vena cava. Some ligated arterial vasculature. Traditionally, the caudate
ardently believe the biliary ductal system should be lobe is spared in formal left hepatic lobe resections, and
managed during intrahepatic dissection to prevent injury therefore, the surgeon should preserve the portal venous
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to the contralateral duct. branches from the left portal vein into this segment. The
For living donor hepatectomies, the hepatic artery, middle and left hepatic veins are then divided with a
portal vein, and hepatic vein branches are kept intact laparoscopic stapling device, and parenchymal transec-
as the parenchymal division is completed. The patient tion begins in the standard fashion.
is then heparinized prior to the dissection of the target In a recent study, some compared experience of
vascular structures and ultimate division. Subsequently, conventional open liver resection to laparoscopic liver
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the specimen is removed through the hand port site. resection. As expectant, the laparoscopic approach with
hand assistance and parenchymal dissection through the
RighT hepATeCTomy uSing hand port incision had equivalent operative metrics with
The hyBRid TeChnique shortened length of stay. 14,15 Koffron et al have shown
that laparoscopic resection is less expensive because of
After mobilization of the right hepatic lobe by division
of the falciform and triangular ligaments, exsufflate the the shortened hospital stay. This finding reflects what
abdomen, remove the hand port, and secure the retractor has already been conclusively shown with laparoscopic
system to expose the liver through the midline abdominal cholecystectomy, fundoplication, and gastric bypass
16,17
incision. Next, place lap pads behind the liver to bring surgery.
the hilum into better view.
Prior to dissection, methodically palpate for a replaced ConCLuSion
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right hepatic artery. The middle hepatic artery can be Since Dr Jean Louis Lortat-Jacob detailed the first pub-
easily mistaken for a right hepatic artery, especially in lished hepatectomy using the roadmap laid out by Claude
the setting of a replaced artery, and division can have Couinaud, the field of liver surgery has seen a celebrated
severe implications for segments 4A and 4B. rise in the capability to offer resection with lower rates of
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