Introduction

Laparoscopic liver resection was first performed over two decades ago and is widely adopted in many institutions worldwide today [1]. However, laparoscopic liver resection especially for major hepatectomies remains a highly complicated and technically demanding procedure and is routinely performed only by specialized surgeons in high-volume centers today [2, 3]. In this chapter, we share the operative techniques adopted at our institution based on our experience with over 800 laparoscopic liver resections performed to date [1, 2, 4, 5].

Surgical Technique

Position

  1. 1.

    Reverse Trendelenburg position.

  2. 2.

    Supine position with primary operator on the right side.

  3. 3.

    Alternative position: Supine with both limbs abducted and surgeon stands between the legs.

Access and Port Position

  1. 1.

    Usually 5–6 ports are used (another 5 mm port may be used for application of the extracorporeal Pringles maneuver.

  2. 2.

    Place an initial 12 mm port for the camera at the right hypochondrium (4–5 cm from the midline).

  3. 3.

    Place two 12 mm working ports to the right and left of the initial port (about 5 cm from the camera port.

  4. 4.

    Insert another two 5 mm assistant ports at right subcostal and epigastrium.

  5. 5.

    Place another 5 mm port in the left hypochondrium if the extracorporeal Pringles Maneuver is used.

Scope and Pneumoperitoneum

  1. 1.

    A rigid 30°–10 mm laparoscope or a flexible tip 0°–10 mm laparoscope.

  2. 2.

    Set CO2 pressure at 12 mmHg with high flow.

  3. 3.

    Two gas insufflators or the AirSeal device may be used to maintain a constant pneumoperitoneum.

Exploration

  1. 1.

    Use of intraoperative laparoscopic ultrasound is imperative to determine the size and location of the lesions and to identify additional lesions.

  2. 2.

    To identify key anatomical structures/landmarks such as the right hepatic vein, middle hepatic vein (MHV) (which is critical in guiding parenchyma transection), and the right Glissonian pedicle (including right anterior and right posterior pedicles.

Mobilization

  1. 1.

    Use monopolar energy to divide the ligaments of the liver (the round, falciform, and triangular ligaments).

  2. 2.

    Divide both the right and left triangular, and coronary ligaments according to the site of the lesion.

  3. 3.

    Rotating the table clockwise will allow gravity to assist in liver mobilization.

  4. 4.

    Mobilize the liver off the inferior vena cava (IVC) taking the short hepatic veins in a caudal to cranial direction (be aware of possible large inferior right hepatic veins which can be identified on preoperative imaging) (the IVC should be flat implying a low central venous pressure).

  5. 5.

    Division of the IVC ligament is critical to enable division of the right hepatic vein later.

  6. 6.

    It may not always be possible to mobilize the liver completely off the cava especially cranially in all patients (especially with liver having a long craniocaudal diameter). This can be done later after transection of the liver parenchyma.

  7. 7.

    This step of mobilization of the liver can also be performed after parenchymal transection instead of being performed as the initial step as in the medial to lateral approach. This is especially useful for patients with a large right lobe or in the presence of a bulky tumor.

  8. 8.

    Prepare Pringle’s maneuver: encircle the porta hepatis with tape and pass it outside the abdomen through a 5 mm port.

Inflow Control

  1. 1.

    After cholecystectomy, proceed to dissect and identify the inflow structures (after dividing the cystic artery and duct, the gallbladder can be left attached to the liver to aid in retraction during hilar dissection).

  2. 2.

    Inflow control can be obtained via several approaches:

    1. (a)

      The classical extrahepatic intrafascial approach.

    2. (b)

      Extrahepatic Glissonian Approach.

    3. (c)

      Intrahepatic Glissonian Approach.

  3. 3.

    Extrahepatic dissection:

    1. (a)

      This approach is essential for living donor hepatectomy and tumors located close to the hilum.

    2. (b)

      Right hepatic artery is usually identified posterior to right hepatic duct and anterior to the right portal vein.

    3. (c)

      Right portal vein is dissected from the Glissonian sheath identifying the bifurcation with the left portal vein. Division of the caudate branch is useful to obtain additional length on the right portal vein. The portal vein is encircled with a tie.

    4. (d)

      Test clamping of the right portal vein and right hepatic artery should be performed to identify the ischemic line prior to ligating these structures.

    5. (e)

      Indocyanine green by negative staining may be used to aid in the identification of the ischemic line, especially in cases with chemo-damaged liver or cirrhosis.

    6. (f)

      At least two clips should be placed to the staying side of the right hepatic artery and portal vein to reduce the risk of slippage and postoperative bleeding.

    7. (g)

      The right hepatic duct is divided only after wide parenchyma transection to reduce the risk of common hepatic duct stricture.

  4. 4.

    In the extrahepatic Glissonian approach to the right pedicle, identification of the bloodless space between Laennec’s capsule and the Glissonian sheath as described by Suigioka et al. [6] is essential.

  5. 5.

    In the intrahepatic Glissonian approach, the hepatic parenchyma is transected anteriorly and posteriorly to the right pedicle or alternatively small hepatectomies as described by Machado et al. [7] can be created.

  6. 6.

    Both extrahepatic and intrahepatic Glissonian approaches are generally quicker to perform compared to the classical extrahepatic interfacial approach.

  7. 7.

    An important point to note is that a complete 360° dissection of the Glissonian pedicle is not essential and may result in troublesome bleeding as the terminal branches for the MHV are in close proximity. Usually, dissection of about 180°–270° of the right Glissonian pedicle is adequate to allow application of the laparoscopic bull-dog clamps and identification of the ischemic line.

  8. 8.

    Division of the Glissonian pedicle can be performed safely with vascular staplers after the liver parenchyma has been transected widely including transection of segment IX.

  9. 9.

    It must be ensured that the stapler is applied away from the hepatic duct bifurcation to avoid common hepatic duct stricture.

  10. 10.

    When feasible especially in the presence of a short right Glissonian pedicle, separate division of the right anterior and posterior pedicles will avoid accidental narrowing of the common hepatic duct.

Parenchyma Transection

  1. 1.

    This is usually performed with a Cavitron Ultrasonic Surgical Aspirator in combination with an energy device such as harmonic scalpel (Ethicon, USA) or Thunderbeat (Olympus, Japan). A bipolar forceps is also essential. Use intraoperative ultrasound intermittently to guide the transection plane.

  2. 2.

    Small (<5 mm) biliovascular structures can be divided with the energy device.

  3. 3.

    Larger structures are clipped with metal clips or self-locking clips.

  4. 4.

    Reducing the number of clips applied unnecessarily is important to minimize clip slippage.

  5. 5.

    It is useful to perform transection of the paracaval portion of the caudate early to allow control of the right hilar structures.

  6. 6.

    Transection of the hepatic parenchyma proceeds in a caudo-cranial direction along the MHV and the two lobes of the liver are gradually separated like an open book. Segment V tributaries are easily identified and divided.

  7. 7.

    Once the parenchyma has been widely transected, the right Glissonian pedicle can be divided with clips or vascular stapler (if this has not been done previously as with the extrahepatic or intrahepatic Glissonian approach).

  8. 8.

    Parenchyma transection continues cranially along the MHV and careful identification of segment VIII hepatic vein branches especially of segment VIII ventral is critical to avoid shearing of these venous tributaries from the MHV resulting in troublesome bleeding.

  9. 9.

    Finally, the root of the right vein is isolated and this is stapled off with the vascular (white reload).

  10. 10.

    Vascular clamps should always be ready at this final step as a misfire of the stapler can result in catastrophic bleeding.

  11. 11.

    After completion of transection, the liver surface should be inspected for bile leak and bleeding. This should be performed with a Valsalva maneuver after rehydration of the patient and with the pneumoperitoneum lowered to about 5 mmHg.

  12. 12.

    Hemostatic adjuncts may be used on the transected liver parenchyma surface.

  13. 13.

    A closed suction drain is placed in selected cases.

Extraction

  1. 1.

    The specimen is placed in a large bag and extracted via a lower midline or Pfannenstiel incision.

  2. 2.

    Usually, a 6–8 cm incision is required for extraction.