Careful control of haemostasis is particularly important in laparoscopic hepatic surgery, since a bloodless operative field results in safer and smoother procedures. A selective vascular control for a left lateral segmentectomy may be facilitated by the use of three-dimensional (3D) virtual reality.
Materials and methods
A 67-year-old male patient presenting with a 3.5-cm hepatocellular carcinoma (HCC) located between segment II and III of the liver was referred for hepatic resection. Transplant was contraindicated due to previous head and neck cancer surgery. Preoperative 3D reconstruction was used for preoperative planning and allowed a virtual resection to be done as well as peroperative simulation.
Five ports were used. The first step was primary control of the hepatic pedicle. 3D virtual-reality reconstruction demonstrated the position of the tumor in the segment and regarding the vessels. The left hepatic artery and the portal vein were successively dissected and controlled. The real anatomy was compared to the virtual-reality reconstruction. Both demonstrated the same anatomy. Vascular section was completed and this resulted in a typical color change of the left lateral segment as well as a small decrease in size. The bisegmentectomy was performed using harmonic dissectors (Autosonix®, Tyco Healthcare), bipolar cautery, clips, and application of Endo GIA vascular staples (Tyco Healthcare) on the portal pedicles. The procedure was completed following isolation and control of the left hepatic vein. After section, the specimen was placed in a bag and extracted following enlargement of the camera port. Follow-up was uneventful and there was no elevation of hepatic enzymes or postoperative ascites. The patient left the hospital on the fifth postoperative day.
3D reconstruction allowed the procedure to be simulated preoperatively. This facilitated the intraoperative identification of the vascular anatomy and the control of the left lateral segment arteries and veins, thus preventing intraoperative bleeding. The use of this approach in preoperative planning is recommended.
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Descottes B, Glineur D, Lachachi F, Valleix D, Paineau J, Hamy A, Morino M, Bismuth H, Castaing D, Savier E, Honore P, Detry O, Legrand M, Azagra JS, Goergen M, Ceuterick M, Marescaux J, Mutter D, de Hemptinne B, Troisi R, Weerts J, Dallemagne B, Jehaes C, Gelin M, Donckier V, Aerts R, Topal B, Bertrand C, Mansvelt B, Van Krunckelsven L, Herman D, Kint M, Totte E, Schockmel R, Gigot JF (2003) Laparoscopic liver resection of benign liver tumors. Surg Endosc 17:23–30
Gigot JF, Glineur D, Azagra JS, Goergen M, Ceuterick M, Morino M, Etienne M, Marescaux J, Mutter D, van Krunckelsven L, Descottes B, Valleix D, Lachachi F, Bertrand C, Mansvelt B, Hubens G, Saey JP, Schockmel R (2002) Laparoscopic liver resection for malignant liver tumors. Preliminary results of a muticenter European study. Ann Surg 236:90–7
Cherqui D, Husson E, Hammoud R et al (2000) Laparoscopic liver resections: a feasibility study in 30 patients. Ann Surg 232:753–762
Couinaud C (1999) Liver anatomy: portal (and suprahepatic) or biliary segmentation. Dig Surg 16:459–467
Kaneko H, Takagi S, Shiba T (1996) Laparoscopic partial hepatectomy and left lateral segmentectomy: technique and results of a clinical series. Surgery 120:448–475
Azagra JS, Goergen M, Gilbart E, Jacobs D (1996) Laparoscopic anatomical (hepatic) left lateral segmentectomy—technical aspects. Surg Endosc 10:758–761
Huscher CGS, Lirici MM, Chiodini S (1998) Laparoscopic liver resections. Semin Laparosc Surg 5:204–210
Lesurtel M, Cherqui D, Laurent A, Tayar C, Fagniez PL (2003) Laparoscopic versus open left lateral hepatic lobectomy: a case–control study. J Am Coll Surg 196:236–242
Numminen K, Sipilä O, Mäkisalo H (2005) Preoperative hepatic 3D models: virtual liver resection using three-dimensional imaging technique. Eur J Radiol 56:179–184
Marescaux J, Clément JM, Tassetti V, Koehl C, Russier Y, Cotin S, Mutter D, Delingette H, Ayache N (1998) Virtual reality applied to hepatic surgery simulation: the next revolution. Ann Surg 228:627–634
Soler L, Delingette H, Malandain G, Montagnat J, Ayache N, Koehl C, Dourthe O, Malassagne B, Smith M, Mutter D, Marescaux J (2001) Fully automatic anatomical, pathological and functional segmentation from CT scans for hepatic surgery. Comput Aided Surg 6:131–142
Soler L, Forest C, Nicolau S, Vayssiere C, Wattiez A, Marescaux J (2007) Computer-assisted operative procedure: from preoperative planning to simulation. Eur Clinics Obstet Gynaecol 2:201–208
Kamiyama T, Nakagawa T, Nakanishi K, Kamachi H, Onodera Y, Matsushita M, Todo S (2006) Preoperative evaluation of hepatic vasculature by three-dimensional computed tomography in patients undergoing hepatectomy. World J Surg 30:400–409
Marescaux J, Rubino F, Arenas M, Mutter D, Soler L (2004) Augmented reality-assisted laparoscopic adrenalectomy. JAMA 18:2214–2215
Yamanaka J; Saito S, Iimuro Y, Hirano T, Okada T, Kuroda N, Sugimoto T, Fujimoto J (2006) The impact of 3-D virtual hepatectomy simulation in living-donor liver transplantation. J Hepatobiliary Pacreat Surg 13:363–369
Slicer. http://www.slicer.org, Accessed 15 March 2008
Demartines N, Mutter D, Vix M, Leroy J, Glatz D, Rosel F, Harder F, Marescaux J (2000) Assessment of telematic applications in surgery for surgical education and patient care. Ann Surg 231:282–291
Gallagher AG, Richie K, McClure N, McGuigan J (2001) Objective psychomotor skills assessment of experienced, junior, and novice laparoscopists with virtual reality. World J Surg 25:1478–1483
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For typical left lobectomy and according to the identification of the anatomy obtained thanks to the preoperative reconstruction, the dissection started by the preparation and control of the vascular elements into the hepatic pedicle. Arteries and portal veins are successively identified and controlled. Vessels addressed to the left lobe are selectively clipped and cut before parenchymal dissection. (MPG 67585 kb)
The realization of the hepatic dissection using all the available devices to perform haemostasis: monopolar cautery, bipolar cautery, clips, sutures, and staplers. The complete control of the vascular structures before the hepatic dissection itself allows the performance of bloodless vascular resection. A harmonic dissector represents a valuable extra device to perform this surgical procedure. Hepatic pedicles for segments III and II and finally for the left hepatic vein are successively dissected and controlled. The specimen is placed into a bag for removal. (MPG 67171 kb)
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Mutter, D., Dallemagne, B., Bailey, C. et al. 3D virtual reality and selective vascular control for laparoscopic left hepatic lobectomy. Surg Endosc 23, 432 (2009). https://doi.org/10.1007/s00464-008-9931-y
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