Laparoscopic Anatomical Right Hepatectomy Using a Four-Incision Anterior Approach: Technical Details and Surgical Outcomes (with Video)

doi:10.21203/rs.3.rs-3751943/v1

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Laparoscopic Anatomical Right Hepatectomy Using a Four-Incision Anterior Approach: Technical Details and Surgical Outcomes (with Video)

https://doi.org/10.21203/rs.3.rs-3751943/v1

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Background

Laparoscopic hepatectomy, characterized by its complexity, poses distinct challenges compared to other laparoscopic procedures. However, with the continuous advancements in laparoscopic techniques, many surgeons have enhanced the feasibility and safety of this approach for carefully selected patients. The purpose of this study is to offer a comprehensive account of the technical aspects and surgical outcomes associated with laparoscopic anatomical right hepatectomy, specifically utilizing a four-incision anterior approach.

Patients and Methods:

A total of 9 patients with primary liver cancer located in the right lobe underwent laparoscopic anatomical right hepatectomy using a four-incision anterior approach. Detailed information regarding the surgical procedure and incision locations was provided. Postoperative outcomes and operative techniques were retrospectively evaluated. Between September 2018 and September 2020, nine laparoscopic right anterior hepatectomies using a four-incision approach were performed on patients with primary liver cancer. The surgical procedure involved several maneuvers, including blocking the Glissonean pedicle, ligation of the right hepatic artery, right branch of the portal vein and the right hepatic duct, removal of the liver parenchyma along the ischemic line and determination of the liver section based on four anatomical landmarks: the right anterior Glissonian pedicle, middle hepatic vein, root of the right hepatic vein, and retrohepatic inferior vena cava. These landmarks facilitated identification of vessels requiring ligation, resulting in reduced bleeding. The article provides clear visualization of these anatomical landmarks following right hepatectomy.

Results:

All patients in this study underwent laparoscopic anatomical right hepatectomy using a four-incision anterior approach for the treatment of liver cancer. The average duration of the operation was 354 minutes, and the estimated blood loss was 250 ml. Importantly, there were no incidents of bile leakage observed post-surgery.

Conclusion:

Proper patient positioning and precise incision placement are crucial factors for ensuring the success of the laparoscopic right anterior hepatectomy procedure. The separation of the extrahepatic Glissonean pedicle at the liver hilum to determine the hepatic resection ischemia line, as well as the identification of liver sections using four anatomical landmarks, are essential steps in the liver resection process. Additional techniques, such as adjusting the patient's posture during the operation, utilizing suction operated by the surgeon's left hand and an ultrasonic scalpel in the right hand, and suturing bleeding vessels, contribute to the safe completion of the procedure. Furthermore, maintaining a low central venous pressure (CVP) can be beneficial in reducing intraoperative bleeding.

laparoscopy

right hepatectomy

four-incision

low central venous pressure

surgical techniques

The rapid development of laparoscopic technology has indeed brought numerous advantages to hepatectomy procedures. These advantages include smaller incisions, minimal damage to the abdominal wall and collateral circulation, shorter hospital stays, and improved accessibility for subsequent treatments. The concept of laparoscopic hepatectomy was initially proposed by Gagner, but its adoption has been relatively limited due to various challenges and risks associated with this surgical approach.

One of the main challenges is the limited operating space within the abdomen, which can make the procedure technically demanding. Additionally, there is a higher risk of intraoperative bleeding compared to open surgery, and laparoscopic suturing can be technically difficult. However, with advancements in surgical techniques and instruments, as well as increased understanding of laparoscopic hepatectomy, more hospitals have started performing this procedure with reduced hemorrhage and complications.

Initially, laparoscopic hepatectomy was mainly indicated for the removal of small tumors located in superficial positions of the liver. However, as laparoscopic technology has advanced, it can now be used for more complex procedures such as partial hepatectomy and hepatic caudate lobectomy. The minimally invasive nature of laparoscopic hepatectomy offers significant advantages in terms of reduced surgical trauma compared to traditional open operations, primarily due to smaller incisions.

It is important to note that laparoscopic hepatectomy requires advanced surgical instruments, equipment, and techniques. However, many hospitals, particularly in low-income countries, face challenges in terms of a lack of highly skilled surgeons proficient in laparoscopic techniques.

The four-incision procedure, although challenging for the leading surgeon, offers the advantage of decreased reliance on the assistant surgeon. Only one instrument is controlled by the assistant, allowing the procedure to commence if the chief surgeon possesses the necessary skills to handle the entire procedure.

In conclusion, laparoscopic hepatectomy has demonstrated numerous advantages, but its adoption has been relatively limited due to various challenges and risks. However, with advancements in surgical techniques and instruments, more hospitals are performing laparoscopic hepatectomy procedures successfully. The four-incision procedure is a technique that can be employed in these procedures, offering certain advantages in terms of decreased reliance on the assistant surgeon.

Patient

A retrospective analysis was conducted on a cohort of 9 patients who underwent laparoscopic anatomical right hepatectomy with a four-incision anterior approach, specifically targeting segments Ⅴ, Ⅵ, Ⅶ, and Ⅷ. The operations took place between September 2018 and September 2020 at The First Affiliated Hospital of Harbin Medical University in Harbin, China.

Surgical procedure

All patients received intravenous and inhalation anesthesia for the surgical procedure. The patient's positioning during the operation plays a critical role in the success of the surgery. Following arterial puncture and internal jugular venipuncture, the patient is positioned in a supine position with the right side of the body elevated at a 60-degree angle. This positioning causes the liver to slope towards the lower left side due to gravity, facilitating adequate exposure of the right lobe of the liver. The process of establishing the four trocars has been previously described in this text(Fig. 1). Throughout the procedure, we maintained the pneumoperitoneum pressure at 10–12 millimeters of mercury, as lower pneumoperitoneum pressure helps to decrease central venous pressure (CVP) and minimize bleeding during liver resection.

The surgeon positioned themself on the left side of the patient while the first assistant stood on the opposite side. The second assistant, responsible for holding the camera, stood on the same side of the patients(Fig. 2).

Following the insertion of the four trocars through the anterior approach, the surgical procedure commenced. The initial step involved the removal of the gallbladder, exposing the gallbladder fossa. Intrathoracic ligation of the right branch of the hepatic artery and portal vein was then performed in the Glisson's capsule. The right hepatic pedicle was subsequently cut using an endo-line stapler. The separation of the left and right halves of the liver was based on the hepatic ischemia line; however, it is important to note that not all patients exhibited a significant ischemic .line.

During parenchymal transection, there is a risk of damaging the intermediate hepatic vein. Therefore, it is crucial to locate and direct the intermediate hepatic vein before proceeding with dissection. The identification of the intermediate hepatic vein can be achieved by tracing the trunk along its branches or utilizing intraoperative ultrasonography (IOUS) to clarify its direction. IOUS also provides valuable images of other important vessels.

The success of laparoscopic hepatectomy relies heavily on achieving stable and complete exposure of the parenchymal transection. This step is crucial for the safe dissection of vital vessels, the Glisson sheath, and the control of intraoperative bleeding. This article focuses on the operator's flexible utilization of the right-handed ultrasonic scalpel and left-handed suction device.

Upon contact with liver tissue, the ultrasonic scalpel exhibits several effects including micro-acoustic flow, cavitation, thermal, and hemostatic effects. Takeo Nomi et al confirmed the feasibility of the clamp-crush technique for laparoscopic hepatectomy[4]. This technique bears resemblance to the "finger fracture technique" wherein rapid clamping with the ultrasonic scalpel exposes blood vessels or bile ducts by cutting off liver tissue. Smaller lesions can be coagulated directly using the ultrasonic scalpel, while thicker vessels require clamping before removal. For larger bile ducts, it is advisable to apply a 4 − 0 non-absorbable nylon suture for ligation before clamping.

Our study demonstrated the safe and effective performance of parenchymal liver transection using the combination of the ultrasonic scalpel and clamp-crush technique. The laparoscopic suction irrigation system played a supportive role by facilitating tissue visualization and blood absorption. Hepatic dissection was carried out by incising the liver parenchyma along the pre-resection line from the shallow to deep regions, moving from the front to the back, ultimately reaching the surface of the inferior vena cava. Right hepatic veins were ligated using vascular clips. Bipolar electrocoagulation proved to be a useful method for managing surface bleeding during parenchymal liver transection. Although the currently available charged coagulation CUSA(Cavitron Ultrasonic Surgical Aspirator) possesses both functions described in this article, its high price restricts its widespread application.

Lastly, the perihepatic ligament was severed, and the right lobe of the liver was placed in a laparoscopic plastic bag before being retrieved through a suprapubic transverse incision.

None of the 9 cases required conversion to open surgery, indicating the success of the laparoscopic approach. Table 1 summarizes the demographic characteristics and perioperative outcomes of the patients. The median duration of the operation was 330 minutes, ranging from 240 to 480 minutes. The median blood loss was 200 mL, varying from 50 to 500 mL. All histopathological evaluations confirmed the presence of hepatocellular carcinoma. Importantly, there were no significant complications observed during the perioperative period, such as liver failure or bile leakage. The median length of hospital stay following the surgery was 10 days, ranging from 5 to 15 days. Moreover, liver function returned to normal levels within 1 month after the surgery.

Table 1

Patients’ information and perioperative results
Sex	Age	Hepatitis	Cirrhosis	Child-Pugh Grade	Pathologic Diagnosis	Tumor Size(cm)	Segments	Operative Time (min)	Intraoperative Blood Loss (mL)	Postoperative Hospital Stay (days)
Female	50	B	Yes	A	HCC	8.0	Ⅵ/Ⅶ	300	200	15
Male	48	B	No	A	HCC	12.0	Ⅴ/Ⅵ/Ⅶ/Ⅷ	420	50	6
Male	50	B	No	A	HCC	9.0	Ⅵ/Ⅶ	330	200	6
Male	54	No	No	A	HCC	8.0	Ⅵ/Ⅶ	430	400	12
Male	51	No	No	A	HCC	10.0	Ⅵ/Ⅶ	330	500	5
Female	67	B	Yes	A	HCC	2.2	Ⅷ	480	300	10
Male	54	B	Yes	A	HCC	5.0	Ⅵ	360	200	12
Female	56	B	No	A	HCC	8.0	Ⅵ/Ⅶ/Ⅷ	240	200	10
Male	47	B	No	A	HCC	5.0	Ⅴ/Ⅷ	300	200	7
HCC:hepatocellular carcinoma;

The secondary injuries in laparoscopic hepatectomy include intraoperative bleeding, diaphragm injury, venous air embolism, and other complications. It is crucial to promptly and accurately identify the type of injury and implement timely and effective strategies when secondary injuries occur.

Reducing intraoperative bleeding through Low Central Venous Pressure (LCVP) is critical. Collaborating with the anesthesiologist, we can measure the central venous pressure (CVP) using a central venous catheter during the operation. Wang et al. ^[5] divided 50 liver resection patients equally into control and LCVP groups. The LCVP group maintained a CVP of 2–4 mmHg intraoperatively. A comparison of the two groups revealed that the total intraoperative blood loss was significantly lower in the LCVP group. R M Jones et al. ^[6] also considered LCVP to be the simplest and most effective method for reducing surgical bleeding. Currently, various methods exist for controlling LCVP, including strict infusion limitation, epidural analgesia, and maintaining a reverse Trendelenburg position ^[7]. Administering norepinephrine resulted in a significant reduction in total hepatic blood flow, mediated by a decrease in hepatic arterial flow ^[8]. A study demonstrated that before performing parenchymal transection, a portion of whole blood could be extracted without diluting coagulation factors to reduce CVP. The withdrawn blood could then be saved and infused back into the patient after completing parenchymal transection in non-tumor patients ^[9].

Laparoscopic suturing for hemostasis technique: Although the Pringle maneuver may help control liver parenchymal hemorrhage, suturing remains the best approach for rapidly controlling intraoperative bleeding ^[10]. Suturing also helps prevent postoperative complications such as liver abscess, which can be caused by damaging the main arteries due to a lack of clear surgical vision, thereby avoiding conversion to open surgery. For smaller breaches at the junction of hepatic veins, hemostatic gauze should be used to stop bleeding. If compression hemostasis is ineffective for larger breaches or in cases of bile duct injury, suturing hemostasis with a 15 cm 4 − 0 prolene suture is the preferred method. The operator should be proficient in operating surgical instruments with two hands: the left hand operates the laparoscopic suction to remove blood from the surgical field and fully expose the bleeding breach of the vein, while the right hand operates the needle driver to suture the breach and tie a figure-eight suture. Goumard et al. ^[11] proposed the use of Pledget-armed sutures for intraoperative bleeding control during laparoscopic hepatectomy. The advantage of Pledget-armed sutures is their ability to avoid suture slipping by providing additional mechanical compression force. Combining the figure-of-eight suture and Pledget-armed suture may achieve better hemostasis.

Diaphragm injury: Due to the high pressure of pneumoperitoneum in the abdominal cavity, diaphragm injuries can occur, leading to the rapid entry of carbon dioxide into the chest cavity through ruptured diaphragms and resulting in pneumothorax. The treatment method involves immediately suturing the rupture, removing gas, and then securely tying the knot. Closed chest drainage systems should be placed in the injured chest cavity.

Carbon dioxide Embolism

The incidence of secondary injuries in laparoscopic hepatectomy, such as CO2 embolism, although relatively low, is higher compared to other laparoscopic procedures. Studies have indicated that it is more advisable to maintain the pneumoperitoneum pressure below 12 mmHg and take into account the relationship between pneumoperitoneum pressure and central venous pressure (CVP) ^[12]. Furthermore, Jayaraman et al. ^[13] suggested that an increased ratio of pneumoperitoneum pressure to CVP could elevate the risk of gas embolism.

If there is an abnormal increase in blood CO2 concentration, decreased blood pressure, or arrhythmia during the laparoscopic procedure, the possibility of gas embolism should be taken into consideration. Once gas embolism is diagnosed, it is crucial to immediately stop the pneumoperitoneum. Reducing intraperitoneal pressure is necessary, and the area surrounding the damaged blood vessel should be submerged in liquid. Prompt identification and ligation of the injured blood vessel should be performed.

In severe cases of gas embolism, aspiration of air bubbles can be done through a central venous catheter or, if necessary, direct right heart puncture can be performed to remove the bubbles. If the situation requires it, conversion to open surgery should be considered.

Bile Leakage

Bile leakage is a common complication that can occur after hepatectomy. Harimoto et al. [14] have proposed that hepatocellular carcinoma (HCC) and ALICE grade 3 are independent predictors of bile leakage in patients undergoing hepatectomy. When these independent predictors are present, it is crucial to perform the operation with caution in order to promptly detect and treat bile leakage.

The incidence of postoperative bile leakage (POBL) has been reported to range from 3.6–11%, and similar results have been observed in laparoscopic hepatectomy ^[15]. Intraoperative bile leakage is relatively common during laparoscopic hepatectomy and represents a significant risk factor for postoperative bile leakage. It is essential to carefully identify and manage POBL during the operation. One method of identifying bile leakage is by observing a yellow discoloration of gauze when wiping the surface of the liver parenchyma.

Timely and effective management of bile leakage during surgery is of utmost importance. In the event of bleeding or bile leakage, caution should be exercised to prevent excessive cauterization, as it could potentially result in biliary tract injury. The surgeon should suture the bile duct stump using a 4 − 0 prolene suture and consider applying suitable hemostatic materials to the surface.

Laparoscopic right hemihepatectomy remains a complex procedure. While the five-port laparoscopic right hemihepatectomy with dual-surgeon mode ensures safety, it is challenging to ensure the availability of two skilled surgeons for each operation in most departments. Consequently, the widespread implementation of this approach is limited. If surgeons can master the four-hole method of laparoscopic right hepatectomy, it will facilitate the performance of complex laparoscopic hepatectomies in more surgical centers.

Author Contributions

Conceived and designed the experiments: Haiyan Yang, Xianbo Shen and Haoling Liu, Analyzed the data: Qingquan Bai, Jiashu Zou, Qian Cao, Wrote the paper: Cong Liu and Maria A. Parra.

Ethical Approval

Ethics approval and consent to participate

The study was approved by the Research Ethics Committee of The First Affiliated Hospital of Harbin Medical University. The procedures used in this study adhere to the tenets of the Declarations of Helsinki. All of the patients agree that their clinical details and accompanying images are published.

Availability of data and materials

Data is available upon reasonable request and with permission of The First Affiliated Hospital of Harbin Medical University.

Funding

The authors declare no funding for this study

Conflict of interest

The authors declare no conflicts of interest that pertain to this work.

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No competing interests reported.

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Laparoscopic Anatomical Right Hepatectomy Using a Four-Incision Anterior Approach: Technical Details and Surgical Outcomes (with Video)

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Version 1

Abstract

Background

Patients and Methods:

Results:

Conclusion:

Figures

Introduction

Patient and Methods

Patient

Surgical procedure

Results

Discussion

Carbon dioxide Embolism

Bile Leakage

Conclusion

Declarations

Author Contributions

Conflict of interest

References

Additional Declarations

Supplementary Files

Status:

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