Minimally invasive resection of posterosuperior liver tumors in the supine position using intra-abdominal trocars

  • Emin Kose
  • Bora Kahramangil
  • Husnu Aydin
  • Mustafa Donmez
  • Federico Aucejo
  • Cristiano Quintini
  • John Fung
  • Eren BerberEmail author



Laparoscopic liver resection (LLR) of posterosuperior (PS) segment liver tumors is technically challenging with confusion about optimal patient positioning and trocar placement (i.e., transabdominal vs. transcostal). The aim of this study is to describe our technique and outcomes with LLR of these tumors.


This is an IRB-approved retrospective review of a prospective database. Between 2005 and 2017, patients with benign and malignant lesions underwent LLR. Perioperative outcomes of PS (segments 4A, 7, and 8) and anterolateral (AL) resections were compared. All patients were operated through intra-abdominal trocars in the supine position.


304 patients underwent LLR for AL (n = 217) and PS (n = 87) segmental lesions. Minor liver resections were performed in 274 patients and major resections in 30. Groups were comparable for age, sex, pathology, and tumor size (mean 4.2 and 3.7 cm for AL and PS). Inflow occlusion was more frequently performed for PS resections, but precoagulation rates were similar. PS resections more frequently required hand assistance (50% vs. 20%, p < 0.001) and conversion to open (18% vs. 7%, p = 0.04). For PS versus AL resections, operative time (253 vs. 205 min, p ≤ 0.001) was longer and associated with more blood loss (307 vs. 211 mL, p < 0.001) and more frequent need for blood transfusion (15% vs. 7%, p = 0.04). However, the rate of negative resection margin, 90-day complication rates, and length of stay were similar between the two groups.


This study shows that LLR of PS located liver tumors is more challenging compared to AL lesions. Nevertheless, it can be performed successfully in the majority of patients with supine positioning and intra-abdominal trocar placement, without compromising oncologic principles. Liberal uses of hand assistance and inflow occlusion were the technical tips helping us to successfully resect these tumors laparoscopically.


Laparoscopic surgery Posterosuperior liver lesions Minimally invasive surgery 


Compliance with ethical standards


No financial support was received for this study. Dr. Berber is a consultant for Ethicon, Medtronic, and Aesculap. He has received honoraria for consulting work from these three companies. Drs. Emin Kose, Bora Kahramangil, Husnu Aydin, Mustafa Donmez, Federico Aucejo, Cristiano Quintini, and John Fung have no conflict of interest or financial ties to disclose.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Emin Kose
    • 1
  • Bora Kahramangil
    • 1
  • Husnu Aydin
    • 1
  • Mustafa Donmez
    • 1
  • Federico Aucejo
    • 2
  • Cristiano Quintini
    • 2
  • John Fung
    • 2
  • Eren Berber
    • 1
    • 2
    Email author
  1. 1.Department of Endocrine SurgeryCleveland ClinicClevelandUSA
  2. 2.Department of General SurgeryCleveland ClinicClevelandUSA

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