Abstract
Background
Hepatectomy may prolong the survival of colorectal cancer patients with liver metastases. Two-stage liver surgery is a valid option for the treatment of bilobar colorectal liver metastasis. This video demonstrates technical aspects of a two-stage pure laparoscopic hepatectomy for bilateral liver metastasis. To the authors’ knowledge, this is the first description of a two-stage laparoscopic liver resection in the English literature.
Methods
A 54-year-old man with right colon cancer and synchronous bilobar colorectal liver metastasis underwent laparoscopic right colon resection followed by oxaliplatin-based chemotherapy. The patient then was referred for surgical treatment of liver metastasis. Liver volumetry showed a small left liver remnant. Surgical planning was for a totally laparoscopic two-stage liver resection. The first stage involved laparoscopic resection of segment 3 and ligature of the right portal vein. The postoperative pathology showed high-grade liver steatosis. After 4 weeks, the left liver had regenerated, and volumetry of left liver was 43%. The second stage involved laparoscopic right hepatectomy using the intrahepatic Glissonian approach. Intrahepatic access to the main right Glissonian pedicle was achieved with two small incisions, and an endoscopic vascular stapling device was inserted between these incisions and fired. The line of liver transection was marked following the ischemic area. Liver transection was accomplished with the Harmonic scalpel and an endoscopic stapling device. The specimen was extracted through a suprapubic incision. The falciform ligament was fixed to maintain the left liver in its original anatomic position, avoiding hepatic vein kinking and outflow syndrome.
Results
The operative time was 90 min for stage 1 and 240 min for stage 2 of the procedure. The recoveries after the first and second operations were uneventful, and the patient was discharged on postoperative days 2 and 7, respectively.
Conclusion
Two-stage liver resections can be performed safely using laparoscopy. The intrahepatic Glissonian approach is a useful tool for pedicle control of the right liver, especially after previous dissection of the hilar plate.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Fong Y, Fortner J, Sun RL, Brennan MF, Blumgart LH (1999) Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1,001 consecutive cases. Ann Surg 230:309–318
Koffron AJ, Auffenberg G, Kung R, Abecassis M (2007) Evaluation of 300 minimally invasive liver resections at a single institution: less is more. Ann Surg 246:385–392
Wicherts DA, Miller R, de Haas RJ, Bitsakou G, Vibert E, Veilhan LA, Azoulay D, Bismuth H, Castaing D, Adam R (2008) Long-term results of two-stage hepatectomy for irresectable colorectal cancer liver metastases. Ann Surg 248:994–1005
Machado MA, Makdissi FF, Bacchella T, Machado MC (2005) Hemihepatic ischemia for laparoscopic liver resection. Surg Laparosc Endosc Percutan Tech 15:180–183
Kianmanesh R, Farges O, Abdalla EK, Sauvanet A, Ruszniewski P, Belghiti J (2003) Right portal vein ligation: a new planned two-step all-surgical approach for complete resection of primary gastrointestinal tumors with multiple bilateral liver metastases. J Am Coll Surg 197:164–170
Capussotti L, Muratore A, Baracchi F, Lelong B, Ferrero A, Regge D, Delpero JR (2008) Portal vein ligation as an efficient method of increasing the future liver remnant volume in the surgical treatment of colorectal metastases. Arch Surg 143:978–982
Machado MA, Herman P, Machado MC (2003) A standardized technique for right segmental liver resections. Arch Surg 138:918–920
Machado MA, Makdissi FF, Galvão FH, Machado MC (2008) Intrahepatic Glissonian approach for laparoscopic right segmental liver resections. Am J Surg 196:e38–e42
Ogata S, Kianmanesh R, Belghiti J (2005) Doppler assessment after right hepatectomy confirms the need to fix the remnant left liver in the anatomical position. Br J Surg 92:592–595
Jaeck D, Oussoultzoglou E, Rosso E, Greget M, Weber JC, Bachellier P (2004) A two-stage hepatectomy procedure combined with portal vein embolization to achieve curative resection for initially unresectable multiple and bilobar colorectal liver metastases. Ann Surg 240:1037–1049
Elias D, De Baere T, Roche A, Ducreux M, Leclere J, Lasser P (1999) During liver regeneration following right portal embolization the growth rate of liver metastases is more rapid than that of the liver parenchyma. Br J Surg 86:784–788
Abdalla EK, Vauthey JN, Ellis LM, Ellis V, Pollock R, Broglio KR, Hess K, Curley SA (2004) Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. Ann Surg 239:818–825
Abdalla EK (2009) Commentary: radiofrequency ablation for colorectal liver metastases: do not blame the biology when it is the technology. Am J Surg 197:737–739
Dagher I, Di Giuro G, Dubrez J, Lainas P, Smadja C, Franco D (2009) Laparoscopic versus open right hepatectomy: a comparative study. Am J Surg 198:173–177
Ayiomamitis GD, Low JK, Alkari B, Lee SH, Ammori BJ (2009) Role of laparoscopic right portal vein ligation in planning staged or major liver resection. J Laparoendosc Adv Surg Tech A 19:409–413
Disclosures
M. A. Machado, F. F. Makdissi, R. C. Surjan, G. T. Kappaz, and N. Yamaguchi have no conflicts of interest or financial ties to disclose.
Author information
Authors and Affiliations
Corresponding author
Electronic supplementary material
Below is the link to the electronic supplementary material.
Supplementary material 1 (WMV 55070 kb)
Rights and permissions
About this article
Cite this article
Machado, M.A., Makdissi, F.F., Surjan, R.C. et al. Two-stage laparoscopic liver resection for bilateral colorectal liver metastasis. Surg Endosc 24, 2044–2047 (2010). https://doi.org/10.1007/s00464-009-0859-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-009-0859-7