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Journal of Gastrointestinal Surgery

, Volume 22, Issue 9, pp 1643–1644 | Cite as

Segment 7 Laparoscopic Liver Resection: Is It Possible to Resect When Metastatic Lesions Border Suprahepatic Veins?

  • Fabrizio Moisan
  • Brice Gayet
  • Marc A. Ward
  • Nicolas Tabchouri
  • David FuksEmail author
Multimedia Article

Abstract

Introduction

After nearly 25 years of experience, laparoscopic liver resection (LLR) is now recognized as being feasible and safe.1 However, laparoscopic resections of the posterosuperior segments are more technically demanding. They are associated with higher conversions rates, more intraoperative bleeding, and increased operating time.2 Appropriate training is required to approach these resections safely.3 This video demonstrates the technical maneuvers to laparoscopically approach a segment 7 tumor in contact with the right supra hepatic vein.

Method

The pertinent aspect to perform a segment 7 metastasis resection using minimally invasive techniques is shown. The main steps of this operation include (1) complete release of the right liver from the coronary and triangular ligament, (2) dissection of the retrohepatic vena cava and transection of the hepatocaval ligament, (3) the use of intercostal trocars for direct vision of the inferior vena cava and the right suprahepatic vein,4,5 (4) the use of intraoperative ultrasound to evaluate the position and limits of vascular structures compared to the lesion, (5) careful transection of the hepatic parenchyma, and (6) dissection of the right hepatic vein to separate it from the lesion.

Results

The surgery was performed in a 68-year-old male patient. The patient developed synchronous metastases to the liver from a sigmoid colon tumor. Two lesions were identified; a 15 mm subcapsular lesion located in segment 5 and a 45 mm lesion located in segment 7 in contact with the right hepatic vein and inferior vena cava confluence. Previously, laparoscopic sigmoidectomy was performed without complications (TNM classification of the specimen: T3N0, with 31 resected lymph nodes, KRAS gene mutated). Following chemotherapy with FOLFOX + bevacizumab, a good response to the liver lesion was noted on imaging. Subsequently, a laparoscopic resection of the metastases in segment 7 and 5 was performed. The surgery lasted 210 min, intraoperative blood loss was 200 cm3, no Pringle maneuver was required, and the postoperative period was uneventful with the patient being discharged on postoperative day number four. Pathology of the liver specimens confirmed metastases from colon adenocarcinoma with free surgical margins.

Discussion

Some important points achieving easier and safer approach of the posterior segments of the liver by laparoscopic route should be discussed. First, the patient’s semi-lateral position showed in the video allows placing the ports and the optic in a more comfortable position since the lateral portion of the abdominal and thoracic wall becomes anterior. Another important point is the complete liberation of the hepatorenal, falciform, triangular, and right coronary ligaments in order to fully mobilize the liver and convert a segment that is posterior in the anatomical position to an anterior segment for the surgeon. And finally, the use of intercostal trocars that allows a direct and perpendicular view of the right hepatic vein and vena cava represents the most important point. Interestingly, these specific trocars should be inserted through the pleural cavity, during a forced expiration or apnea to avoid lung injury. In this context, the trocar balloon helps the surgeon to avoid displacement or that pneumoperitoneum enters the pleural cavity. At the end of the procedure, we strongly recommend to stitch laparoscopically these diaphragmatic openings after removing the trocars in order to avoid migration of abdominal fluid or bowel incarceration into the pleural cavity during the postoperative period and also to avoid future diaphragmatic hernia. In the present case, the parenchymal transection was performed with Thunderbeat (Olympus®, Japan), a device integrating both ultrasound dissection and advanced bipolar energy. We use this device because it saves time by sealing vessels up to 7 mm in diameter avoiding the need to use clips in the majority of intrahepatic veins and portal branches. However, currently, several techniques and devices are equivalent for parenchymal transection in laparoscopic liver resection and should be left to the surgeon’s preference, as in open liver procedures.

Conclusion

Using laparoscopy to remove lesions in the posterior segments of the liver is safe and feasible. Vision from transthoracic port has the added benefit of making the dissection of right hepatic vein and inferior vena cava safer. Mastery of the anatomy is paramount before attempting this approach with minimally invasive techniques. Surgeons who attempt this operation should have expertise with both laparoscopy and liver surgery.

Keywords

Laparoscopic liver resection Posterior liver segments Segment 7 Colorectal metastasis 

Notes

Author’s Contribution

FM, DF, and MW designed the study; FM, NT, and MW acquired the data and edited the video. FM, DF, and NT drafted and revised the paper. BG and DF critically revised all drafts. All five authors approved the final version.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Supplementary material

Video S1

(MP4 316,922 kb)

References

  1. 1.
    Abu Hilal, M. et al. The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation. Ann. Surg. (2017).  https://doi.org/10.1097/SLA.0000000000002524
  2. 2.
    Kawaguchi, Y., Fuks, D., Kokudo, N. & Gayet, B. Difficulty of Laparoscopic Liver Resection: Proposal for a New Classification. Ann. Surg. 267, 13–17 (2018).CrossRefPubMedGoogle Scholar
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    Nomi, T. et al. Learning curve for laparoscopic major hepatectomy. Br. J. Surg. 102, 796–804 (2015).CrossRefPubMedGoogle Scholar
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    Ogiso, S. et al. Laparoscopic Transabdominal With Transdiaphragmatic Access Improves Resection of Difficult Posterosuperior Liver Lesions. Ann. Surg. 262, 358–365 (2015).CrossRefPubMedGoogle Scholar
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    Ishizawa, T., Gumbs, A. A., Kokudo, N. & Gayet, B. Laparoscopic segmentectomy of the liver: from segment I to VIII. Ann. Surg. 256, 959–964 (2012).CrossRefPubMedGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2018

Authors and Affiliations

  • Fabrizio Moisan
    • 1
    • 2
    • 3
  • Brice Gayet
    • 1
    • 4
  • Marc A. Ward
    • 1
    • 5
  • Nicolas Tabchouri
    • 1
    • 4
  • David Fuks
    • 1
    • 4
    Email author
  1. 1.Department of Digestive, Oncologic and Metabolic SurgeryInstitut Mutualiste MontsourisParisFrance
  2. 2.Department of Surgery, Faculty of MedicineUniversidad de ConcepciónConcepciónChile
  3. 3.Surgery Service, Hospital Guillermo Grant Benavente, Concepción Health ServiceConcepciónChile
  4. 4.Université Paris DescartesParisFrance
  5. 5.Department of SurgeryBaylor University Medical CenterDallasUSA

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