Surgical Endoscopy

, 25:3441 | Cite as

Laparoscopic right hepatectomy and partial resection of the diaphragm for liver metastases

  • Andrew A. GumbsEmail author
  • Abraham Leventhal
  • John P. Hoffman



Indications for minimally invasive major hepatectomies have been increasing as experience with these techniques grows. Invasion into the diaphragm is considered a contraindication to the laparoscopic approach. At their institution, the authors have begun approaching all tumors laparoscopically. This report presents the techniques necessary to perform right hepatectomy, partial diaphragm resection, and repair using totally laparoscopic techniques.


Five trocars are placed in a semilunar fashion approximately one handbreadth apart along a line one handbreadth below the right subcostal margin. The hepatic inflow is taken extraparenchymally before transection of the hepatic parenchyma in an anterior-to-posterior fashion. The hepatic inflow then is transected, and the involved portion of diaphragm is transected with ultrasonic shears. Next, the diaphragm is repaired primarily and buttressed with an absorbable material to decrease the incidence of recurrent diaphragmatic hernia.


Laparoscopic treatment was attempted for ten patients and successfully completed for nine of these patients (90%). All 10 patients had secondary liver tumors. Three patients required concomitant partial diaphragm resection. The median estimated blood loss (EBL) was 500 ml (range, 300–3,000 ml). All margins were negative, and the average hospital stay was 8 days (range, 5–17 days). Two patients (20%) experienced complications, which consisted of biliary leaks, which were treated with percutaneous drainage. One of these patients underwent conversion to an open procedure due to an inferior vena cava injury. No mortality occurred at 30 or 90 days of follow-up evaluation.


The minimally invasive approach to secondary tumors requiring right hepatectomy is feasible and safe even when there is diaphragmatic involvement. Larger series with long-term follow-up evaluation are needed to determine whether these short-term results translate into durable benefits.


Hepatic resection Laparoscopy Major liver resection Metastases Minimally invasive liver surgery Right hepatectomy Tumors 



Andrew A. Gumbs is a consultant for Ethicon Biosurgery and a lecturer for Applied Medical. Abraham Leventhal and John P. Hoffman have no conflicts of interest or financial ties to disclosure.

Supplementary material

Supplementary material 1 (MP4 242759 kb)


  1. 1.
    Gumbs AA, Gayet B (2008) Multimedia article: totally laparoscopic extended right hepatectomy. Surg Endosc 22:2076–2077PubMedCrossRefGoogle Scholar
  2. 2.
    Nishioka K, Mitsudomi T, Saitoh G, Maruyama R, Ishida T, Takenaka K, Sugimachi K (1996) Combined resections of the diaphragm and the liver for a locally advanced non-small-cell lung cancer. Respiration 63:314–317PubMedCrossRefGoogle Scholar
  3. 3.
    Favero A, Benzoni E, Zompicchiatti A, Rossit L, Bresadola F, De Anna D, Uzzau A (2007) Surgery in hepatic and extrahepatic colorectal metastases. G Chir 28:307–311PubMedGoogle Scholar
  4. 4.
    Lin MC, Wu CC, Chen JT, Lin CC, Liu TJ (2005) Surgical results of hepatic resection for hepatocellular carcinoma with gross diaphragmatic invasion. Hepatogastroenterology 52:1497–1501PubMedGoogle Scholar
  5. 5.
    Scudamore CH, Shackleton CR, Fache JS, Forward AD, Erb SR (1990) Diaphragmatic resection in association with right hepatectomy. Can J Surg 33:21–24PubMedGoogle Scholar
  6. 6.
    Lubezky N, Sagie B, Keidar A, Szold A (2007) Prosthetic mesh repair of large and recurrent diaphragmatic hernias. Surg Endosc 21:737–741PubMedCrossRefGoogle Scholar
  7. 7.
    Palanivelu C, Rangarajan M, Jategaonkar PA, Parthasarathi R, Balu K (2008) Laparoscopic repair of parahiatal hernias with mesh: a retrospective study. Hernia 12:521–525PubMedCrossRefGoogle Scholar
  8. 8.
    Gumbs AA, Gayet B, Gagner M (2008) Laparoscopic liver resection: when to use the laparoscopic stapler device. HPB Oxford 10:296–303PubMedCrossRefGoogle Scholar
  9. 9.
    Gumbs AA, Crovari F, Vidal C, Henri P, Gayet B (2007) Modified robotic lightweight endoscope (ViKY) validation in vivo in a porcine model. Surg Innov 14:261–264PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Andrew A. Gumbs
    • 1
    Email author
  • Abraham Leventhal
    • 2
  • John P. Hoffman
    • 2
  1. 1.Department of Surgical OncologySummit Medical GroupBerkeley HeightsUSA
  2. 2.Department of Surgical OncologyFox Chase Cancer CenterPhiladelphiaUSA

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