Introduction

Liver resection is basically parenchymal transection and vessels, bile ducts control which is related to risk of major bleeding, bile leak, and unwanted injury of hepatic remnant. Distribution of vessels and bile ducts consists of two parts. One is hepatic veins. The other is hepatic pedicles which are covered by Glisson’s capsule and located deeply in the hepatic parenchyma. This leads to technical difficulties as controlling inflow and outflow. This is explanation for limitation of applying laparoscopic surgery in major anatomical hepatectomy such as right hepatectomy and left hepatectomy.

In recent years, laparoscopic left hepatectomy (LLH) becomes more common all over the world. Its indication includes both benign and malignant liver lesions. Most of laparoscopic left hepatectomy are done in specialized centers with HBP experts. However, it is reported that this procedure is feasible and safe.

Patient Selection

LLH is indicated for:

  1. 1.

    Benign or malignant lesions are located in the left liver (segments 2, 3, 4) while less resection is inappropriate.

  2. 2.

    Donor of the living liver transplantation.

Procedure

Generally, there are many types of laparoscopic approach in left liver resection. They are dorsal approach, Arantius-first approach, glissonean pedicle approach, and anterior approach [1,2,3]. In this chapter, we describe technically LLH with combination of glissonean pedicle approach and anterior approach [3, 4].

Operating Room Setup, Patient Positioning, and Surgical Team

Patient is placed in supine reverse Trendelenburg position. The arms should be tucked at the patient’s sides. The legs are abducted.

Operating room setup is described in (Fig. 1)

Fig. 1
An image of a setup in a surgical procedure where the patient is surrounded by two monitors above his head, a surgeon with a nurse behind on his left side, an assistant on the left side, and the cameraman between his thighs.

OR setup

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Technique

  1. 1.

    Trocar placement

    First 12 mm trocar is placed at the umbilicus.

    Another 12 mm trocar and three 5 mm trocars are placed as in (Fig. 2)

  2. 2.

    Exploration

    Staging is very important in case of malignant or suspected malignant lesions. Abdominal inspection is performed to assess the liver, peritoneal, and mesenteric metastases.

    Intraoperative ultrasonography is very useful to determine the size, location, number of the lesion, satellite nodules, and the level of liver cirrhosis. This helps to decide the resectability or an alternative surgical plan. Indocyanine green (ICG) can also be used for the purpose of exploration.

  3. 3.

    Mobilization of the left liver

    Mobilization of left liver is performed by dividing round ligament, falciform ligament, left coronary ligament and part of right coronary ligament, left triangular ligament, and then hepatogastric ligament. A cholecystectomy is always done in our technique.

  4. 4.

    Hepatic hilum dissection

    We perform Glissonean pedicle dissection according to Takasaki’s technique. As a result, left hepatic pedicle is encircled with a tape. Then, left hepatic pedicle is temporarily clamped with bulldog clamps to confirm the efficacy of pedicle clamping and to visualize the ischemic demarcation line as well (Fig. 3)

  5. 5.

    Parenchymal dissection

    According to the demarcation line on diaphragmatic surface and visceral surface of the liver, the parenchyma is dissected using ultrasonic shears or CUSA (Fig. 4).

    In superficial 2 or 3 cm of liver parenchyma, there are no major vessels. Hence, we can dissect liver parenchyma safely with energy devices. When proceeding to deeper parenchyma, vascular structures should be recognized using crush-clamp technique and clipped before dividing. The parenchymal dissection should be peripheral to central direction with the left side of the middle hepatic vein as the landmark. (Fig. 5).

    Hepatic parenchymal dissection is continued to caudate area. The left hepatic pedicle is then well exposed.

  6. 6.

    Transection of the left hepatic pedicle and left hepatic vein

    The bulldog clamps are removed and the left hepatic pedicle is divided by a vascular stapler. Other alternatives are using large clips, ligation, or suturing before transection. Care should be taken to avoid stenosis of the right hepatic duct (Fig. 5).

    Although the left hepatic pedicle can be divided before parenchymal dissection, we prefer it after parenchymal dissection because of better visualization of the left hepatic pedicle and better free space around it that may lower the risk of bleeding and lower the risk of inadvertent injuries in case of anatomical variation.

    Then comes the separation of the left liver from caudate area.

    After that, left hepatic vein is exposed and divided. Vascular staplers, ligation, or suturing can be used. Care should be taken to avoid injury to the middle hepatic vein.

  7. 7.

    Hemostasis

    Bleeding and bile leakage is carefully inspected. Clips or sutures are used for bleeding and bile leak.

  8. 8.

    Removal of specimen

    Specimen is placed in a retrieval bag. A drain is usually placed close to the raw surface of the liver. The specimen is extracted through expanded incision of umbilical port or Pfannenstiel incision.

Fig. 2
From left to right, Image A is a part exposed for surgical operations with trocars labeled 5 millimeters, 5 millimeters, 12 millimeters, and 10 millimeters, while B is a photograph of the trocar position with scars.

Trocar position

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Fig. 3
A photograph of a surgical procedure on a body part that involves dissection with the use of clamps.

Clamping of left hepatic pedicle

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Fig. 4
A photograph of a surgical procedure on a body part that involves dissection with the use of shears.

Parenchymal dissection

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Fig. 5
A photograph of a surface of a body part labeled middle hepatic vein.

Middle hepatic vein as anatomical landmark

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Complications

The main complication of laparoscopic left hepatectomy is bleeding. It is better to prevent bleeding than to stop bleeding. When bleeding occurs, we have many options including bipolar coagulation, vessel sealing devices, clips, staplers, and sutures. Laparoscopic suturing skill is important in laparoscopic liver resection. When there is no progress in a certain period or uncontrollable bleeding, conversion should be considered.

Summary

Laparoscopic left hepatectomy is more common but technically demanding. Parenchymal dissection should be peripheral to central with middle hepatic vein as the landmark. Bleeding is the most important issue in laparoscopic liver resection.