Routes for virtually guided endoscopic liver resection of subdiaphragmatic liver tumors



Laparoscopic and thoracoscopic/laparoscopic hepatectomy is a safe procedure that has potential advantages over open surgery. However, deeply positioned liver tumors require expert laparoscopic and thoracoscopic/laparoscopic hepatectomy techniques. Using simulated preoperative three-dimensional virtual endoscopy (P3DVE) guidance, we demonstrate herein that a thoracoscopic approach (TA), thoracoscopic–laparoscopic approach (TLA), and laparoscopic approach (LA) are all feasible and safe routes for performing pure laparoscopic and thoracoscopic/laparoscopic resection of liver tumors located in the 4a, 7, and 8 liver subdiaphragmatic areas.


Thirty-eight patients underwent laparoscopic and thoracoscopic/laparoscopic partial liver resection (TA 13 cases, TLA two cases, and LA 23 cases) of the subdiaphragmatic area at Showa University Hospital. All surgical approaches were preoperatively determined based on preoperative 3D virtual endoscopic simulation (P3DVES) visualization and findings using the image processing software SYNAPSE VINCENT®.


Laparoscopic and thoracoscopic/laparoscopic liver resection was successfully performed for all cases under P3DVE instruction. The mean operative times using TA, TLA, and LA approaches were 193, 185, and 190 min, respectively. Mean blood loss during TA, TLA, and LA was 179, 138, and 73 g, respectively. No patients required conversion to open surgery, and there were no deaths, although there were three cases of Clavien–Dindo grade I in TA along with three cases of grade I and one case of grade II in LA.


TA, TLA, and LA routes performed under P3DVE instruction are feasible and safe to perform for pure laparoscopic and thoracoscopic/laparoscopic liver resection in selected patients with lesions located in the hepatic subdiaphragmatic area.

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Authors’ contributions

Study conception and design: Takeshi Aoki and Masahiko Murakami

Acquisition of data: Akira Fujimori, Tomotake Koizumi, Yuta Enami, Tomokazu Kusano, Kazuhiro Matsuda, and Kosuke Yamada

Analysis and interpretation of data: Koji Nogaki, Yusuke Wada, Tomoki Hakozaki, Satoru Goto, Makoto Watanabe, and Koji Otsuka

Drafting of manuscript: Takeshi Aoki

Critical revision of manuscript: Masahiko Murakami

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Correspondence to Takeshi Aoki.

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Aoki, T., Murakami, M., Fujimori, A. et al. Routes for virtually guided endoscopic liver resection of subdiaphragmatic liver tumors. Langenbecks Arch Surg 401, 263–273 (2016).

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  • Laparoscopic hepatectomy
  • 3D virtual endoscopic simulation
  • Subdiaphragmatic liver tumor
  • Video-assisted thoracoscopic surgery-hepatectomy
  • Thoracoscopic–laparoscopic hepatectomy