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Laparoscopic Two-stage Hepatectomy
Strategy for Hepatectomy laparoscopic and open approaches. Generally, mobilization of the
Two-stage hepatectomy was indicated for advanced metastases right hemiliver is performed laparoscopically, and transection of
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requiring extensive liver resection. A prediction score of 50 or liver parenchyma is performed under minimum laparotomy as
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more, calculated using the formula −84.6 + 0.933a + 1.11b + 0.999c previously reported. Planning for the second procedure must be
with a as the anticipated resection fraction (%), b as the indocyanine flexible, with minimization when FLR hypertrophy is suboptimal.
green retention rate at 15 minutes (ICGR15, %), and c as patient age Multiple small resections avoiding excessive tumor-free margins
in years indicated treatment with a two-stage hepatectomy. are performed using an open approach.
Most first procedures involved resection of metastases from Terminology and Analyzed Parameters
the hemiliver intended to become the future liver remnant (FLR),
followed by portal vein embolization (PVE) directed to the contralateral The Brisbane 2000 terminology of the International Hepato-
hemiliver. FLR volume was measured by computed tomography Pancreato-Biliary Association was used to designate operative
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3 weeks after the first hepatectomy. The second hepatectomy to procedures. Morbidities were assessed according to the Clavien–
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resect the deportalized hemiliver typically was performed 4 weeks Dindo (CD) classification.
after the first procedure. When FLR volume was considered insufficient, Statistical Analysis
completion surgery was postponed until sufficient FLR volume was
attained or a smaller hepatectomy that initially planned was considered Continuous variables, analyzed using the Mann–Whitney U test, are
because of rapid tumor growth during the interval period. expressed as the mean ± standard deviation. Categorical variables,
expressed as numbers followed by percentages in parentheses,
Laparoscopic Procedures were analyzed with Fisher’s exact test. A difference was considered
The laparoscopic procedure began with the open insertion of an significant when the two-sided p-value was below 0.05. All statistical
umbilical 12-mm port; five or six additional ports were used as well. analyses were carried out using SPSS statistical software (version
Diagnostic laparoscopy was performed initially to confirm the absence 23; IBC SPSS, Chicago, Illinois).
of metastases in extrahepatic sites. Liver parenchymal transection
was performed while maintaining a 12 mm Hg pneumoperitoneum, results
which was increased to up to 20 mm Hg if bleeding was encountered. Details of three patients with laparoscopic two-stage hepatectomy
Laparoscopic intraoperative ultrasonography was used routinely to (two men, and one woman; mean age, 67.0 ± 7.2 years) are shown
guide resection and confirm resectability. Parenchymal transection in Table 1. The first-stage hepatectomy consisted of laparoscopic
was performed with a combination of a cavitron ultrasonic surgical lateral sectionectomy or resection of segment 3. All three patients
aspirator system (Valley Lab, Boulder, Colorado) and a soft- underwent PVE to the contralateral hemiliver via the iliac vein
coagulation system (ERBE Elektromedizin, Tübingen, Germany). during the first-stage laparoscopic hepatectomy. Second-stage
During parenchymal transection, Pringle’s maneuver was performed hepatectomy was performed after a mean interval of 37.3 ± 10.7 days
to control vascular inflow, with 15 minutes of occlusion followed by following first-stage resection. Adhesions were considered minimal
5 minutes of release. The resected specimen was placed in a plastic on assessment during the second-stage procedure in all patients.
bag and retrieved through the umbilical incision after both cranial Metastatic tumors were removed from the right hemiliver at second-
and caudal extensions. stage hepatectomy using an open approach in two patients and
PVE was attempted through the extended umbilical incision a hybrid laparoscopic and open approach in the other patient. In
after retrieval of the specimen. The ileum was pulled out through the the two patients undergoing open second-stage hepatectomy,
extended incision. For PVE, a 7-Fr catheter was inserted through an part of the deportalized hemiliver was left in place because
ileocolic vein, after which the portal branches of the hemiliver targeted remnant liver hypertrophy and liver function were compromised
for resection were embolized. The embolic material was a mixture by prehepatectomy chemotherapy. We resected segment 8 and
of gelatin pellets (Gelfoam powder; Upjohn, Kalamazoo, Michigan) performed multiple partial hepatectomies in one patient. Another
and oleic acid monoethanolamine (Oldamine; Grelan, Tokyo, Japan). underwent resection of segment 7 extending to 8 in addition to
After restaging following PVE, patients were suitably scheduled for resection of the right hepatic vein (with preservation of the right
a second-stage resection to remove tumors from the remnant liver. inferior hepatic vein) and partial resection of segments 5 and 6. The
Our standard approach at the second-stage hepatectomy third patient was treated with a hybrid approach including posterior
following a laparoscopic first hepatectomy is a hybrid of sectionectomy extended to segment 8 with preservation of the right
Table 1: Characteristics and operative feasibility of patients undergoing two-stage hepatectomy
Resected Duration, Blood loss, Hospital
No. of Maximum Procedures volume, gm minute mL Morbidity, % stay, days
Gender tumors diameter, mm PVE First/second First/second First/second First/second First/second First/second
1 Male 11 35 Performed Lateral section/ 175/223 230/374 500/700 None/none 8/10
segment 8 + P
2 Female 6 40 Performed Lateral section/ 190/317 255/455 378/700 None/CD-I 5/14
Ext. posterior
section
3 Male 5 33 Performed Segment 3/Ext. 54/264 238/559 380/635 None/CD-IIIb 9/31
segment 7 + P
No., number; PVE, portal vein embolization; first, first hepatectomy; second, second hepatectomy; section, sectionectomy; segment, segmentectomy;
P, partial hepatectomy; Ext., extended to; CD, Clavien–Dindo

World Journal of Laparoscopic Surgery, Volume 14 Issue 2 (May–August 2021) 91