Hepatoblastoma (HB) is the most common liver malignancy in children. Due to hidden symptoms at early stage and inability of infants to speak, many HB lesions are already too large to be resected upon the first visit. Fortunately, HB is usually sensitive to chemotherapy, and the tumor volume may reduce significantly after 3–5 cycles of neoadjuvant chemotherapy, making the lesions fit for resection. In recent years the rising and popularization of minimally invasive surgical procedure have been witnessed. Although some children with smaller neuroblastoma and nephroblastoma lesions have been successfully treated by laparoscopy, laparoscopic resection of giant HB in infants is still disputable and challenging, with few reports raising the concern of this topic.
In the present study, staged laparoscopic resection was performed in 3 infants with giant HB. The purpose of stage one surgery is to reduce blood supply to the tumors. This will cause the tumor volume to shrink and reduce intraoperative blood loss in stage two surgery, thus raising the success rate and lowering the risk of stage two resection. In these three cases, CTA revealed that the tumors were mainly supplied by the hepatic artery. Therefore, we firstly proposed the thoughts of stage one laparoscopic selective hepatic artery ligation and liver partial partition, with stage two laparoscopic hemihepatectomy two weeks later. Compared with simple selective interventional hepatic artery embolization, liver partial partition can further reduce lateral blood supply to the tumor, therefore achieving a better effect. Our clinical results indicated that although the tumor volume shrank significantly after 4–5 cycles of neoadjuvant chemotherapy, the tumors were still too large for one-stage laparoscopic resection. At two weeks after laparoscopic selective hepatic artery ligation and liver partial partition, CT scan indicated further tumor shrinkage in all 3 cases. Moreover, the intratumoral necrosis expanded. Hence favorable condition was created for successful stage two laparoscopic hemihepatectomy.
If the bile duct is ligated in stage one surgery, the risk of biliary fistula, infection and cholestasis will be increased ; if the hepatic artery on the affected side and portal vein are simultaneously ligated, it may cause necrosis of the affected half of the liver and serious consequences. In order to reduce the incidence of complications following the cut of great vessels and bile duct, we only selectively ligated the hepatic artery on the affected side with partial division of liver parenchyma. Meanwhile, fibrin sealant was applied to the wound surface of liver for hemostasis and to prevent adhesion, bleeding and biliary fistula, and the dividing depth was about 2.5 cm. However, more discussion is needed as to the optimal dividing depth. None of our cases had postoperative complications, such as biliary fistula, bleeding and infection.
There is worry that the specimen bag may be ruptured, leading to tumor spread and implantation. The conventional method is to make an incision of about 7–8 cm in the lower abdomen to directly take out the entire specimen . During the operation, the resected half of the liver should be carefully placed into the specimen bag and remained intact, and care should be given not to damage the surface of the tumor. As long as the surgical procedures mentioned above are done cautiously, tumor recurrence and implantation at the incision and Trocar ports are very rare  . None of the specimen bags ruptured in the present study, and neither were there peritoneal implantation and recurrence at the incision and Trocar ports.