Laparoscopic liver resection under hemihepatic vascular in flow occlusion using the lowering of hilar plate approach

Foshan,China

Introduction

Minimally invasive surgery greatly impacts surgery and is practiced in the past two decades.Laparoscopic liver resection can now be performed using new instruments which allow relatively little blood loss and low mortality.It is well-known that excessive intraoperative blood loss together with subsequent blood transfusion increase postoperative morbidity and mortality,and enhance tumor recurrence in patients with liver malignancy.To reduce blood loss during liver parenchymal transection,the Pringle's maneuver is often used.Unfortunately,this maneuver causes ischemic-reperfusion injury to the remnant liver.To further improve laparoscopic liver resection,researchers have explored safe and efficient vascular control techniques.[1-3]

This article describes the technical aspects and the short-term outcomes of total laparoscopic liver resection under hemihepatic vascular in flow occlusion using the lowering of hilar plate approach with the help of biliary bougie.

Methods

From November 2011 to August 2012,eight consecutive patients underwent laparoscopic liver resection under hemihepatic vascular in flow occlusion using the lowering of hilar plate approach.The following data were collected prospectively:the duration of surgery,average time taken to achieve hemihepatic vascular in flow occlusion,perioperative blood transfusion,postoperative complications,and hospital stay.The selection criteria for the procedures were tumors of less than 5 cm,lesions in peripheral liver segments and no hilar involvement.

Surgical technique

The patient was placed in a supine leg-splitting position.We used 4 to 5 trocars.A 10-mm trocar was placed below the umbilicus and pneumoperitoneum was established at a pressure of 12 mmHg.The trocar used for dissection in lowering the hilar plate was placed just above the isplateral side of the hilar plate which was intended to be lowered.Another 2 ports for the assistant were placed according to the site of the liver lesion (Fig.1).Exploration of the abdominal cavity and intraoperative ultrasound liver examination were performed routinely for detection of lesions and design of resection plane.

Fig.1.Positions of the ports.A:right-sided liver resection; B:leftsided liver resection.

The falciform ligament was first divided followed by the round ligament.The lesser omentum was divided at the under surface of the liver to enter into the lesser sac.Cholecystectomy,if necessary,was carried out.The round ligament was retracted upwards and forwards to expose the hepaticoduodenal ligament.The angle between the under surface of the liver and the left pedicle of the hepaticoduodenal ligament should be over 90°.A small incision was made in the Glisson's capsule at its base,similar to the open technique as described by Hepp and Couinaud in 1956.[4]The hilar plate was identified and the plane between the liver and the hilar plate was dissected using blunt dissection with forceps and a small gauze.After the con fluence and the upper part of the right and left hilar pedicles were dissected,a Fr 5 biliary bougie was introduced into the abdomen cavity.The end of the bougie was bent at 90°-100° and it was then inserted into the space between the liver above and the hilar plate below (Fig.2).The bougie bluntly dissected the back of the con fluence of the hilar pedicle.The bougie was guided to exit at the back of the left hepatic pedicle by making a small incision in the peritoneum.By gently moving the bougie,the established tunnel was widened.A similar incision was then made in the peritoneum posterior to the right pedicle,if necessary,to create a tunnel around the right pedicle (Fig.3).A sling was then passed twice either around the left,or the right hepatic pedicle,thus establishing either left- or right-sided hemihepatic vascular in flow occlusion (Fig.4).For right hepatectomy,the right hepatic pedicle was transected with endostapler first.For other resections,the hepatic pedicle was controlled with sling tightening.The contralateral hepatic pedicle was not clamped.Liver transection was then carried out using either an ultrasonic dissector or a harmonic scalpel.The intrahepatic vascular branches were controlled with titanium clips,vascular locks or suturing as appropriate.Control of hepatic vein(s) was similar to the other techniques of total laparoscopic liver resection.The resected specimen was removed by enlarging one of the laparoscopic port wounds.

Fig.2.Operative photograph showing a Fr 5 biliary bougie being inserted into the space between the liver above and the hilar plate below (arrow).

Fig.3.Operative photograph showing a bougie,after establishing a tunnel,exited in the peritoneum posterior to the right hepatic pedicle (arrow).

Fig.4.Schematic diagrams showing (A) dissecting the space between the liver above and the hilar plate below in the "lowering of the liver plate approach"; (B) a Fr 5 biliary bougie placed in the space between the liver above and the hilar plate below after"lowering the liver plate approach"; (C) exit of the biliary bougie on the right side; (D) exit of the biliary bougie on the left side.

Results

This cohort comprised eight consecutive patients,3 women and 5 men with a mean age of 50 years (range 28-68).Five patients had hepatocellular carcinoma(HCC),2 had primary hepatolithiasis,and 1 had focal nodular hyperplasia (FNH).The diagnosis of FNH was preoperatively uncertain and was pathologically confirmed after surgery.Four patients had cirrhosis.The liver functional status was Child A (n=5) and B (n=3).The types of liver resection included right hepatectomy (n=1),right posterior sectionectomy(n=1),left hepatectomy and common bile duct exploration (n=1),segment 4b resection (n=1),left lateral sectionectomy (n=2),and wedge resection (n=2).The three patients with Child's B liver function just received minor resections:wedge resection (n=2) for segment 6 HCC and left lateral sectionectomy (n=1) for HCCs,respectively.Four patients underwent right and 4 patients underwent left hemihepatic vascular in flow occlusion.For left lateral sectionectomy,hemihepatic vascular in flow control was used also because of the advantage of decreasing blood loss and avoiding ischemic-reperfusion injury which was common because of complete vascular in flow occlusion to the right liver.

The mean operation time was 176.3 minutes (range 90-320).The mean time taken to achieve hemihepatic vascular in flow occlusion was 24.3 minutes (range 5-45).The mean intraoperative blood loss was 361 mL(range 70-1500).One of our patients who underwent right posterior sectionectomy had a high blood loss because of the large area of liver transection plane.No patient required blood transfusion.The mean duration of vascular control was 54.5 minutes (range 30-86).Intermittent vascular control with cycles of 15 minutes clamp time/5 minutes unclamp time was used.The conversion rate was 0%.The patient with vascular control time of 86 minutes received right posterior sectionectomy.This patient developed bile leak,which healed after conservative treatment.No patient developed postoperative liver failure.There was no postoperative mortality.The mean hospital stay was 7 days (range 4-13).The resection margins of the 5 patients with HCC were clear.

Discussion

The Pringle's maneuver,because of its effectiveness and simplicity,is a conventional but the most commonly used method to decrease blood loss during hepatic parenchymal transection.[5]It is generally well-tolerated.However,it may induce ischemia-reperfusion injury to the remnant liver,the degree of which is accentuated in the presence of cirrhosis.Hemihepatic vascular in flow occlusion was pioneered by Makuuchi et al.[6]It selectively interrupts the arterial and portal in flow to the ipsilateral right or left hemiliver containing the lesion which requires resection.The advantages of hemihepatic vascular in flow occlusion include avoidance of ischemia to the remnant liver,prevention of splanchnic congestion,and maintenance of hemodynamic stability during liver transection.The only drawback is the potential bleeding from the remnant (non-occluded)hemiliver during liver parenchymal transection.[7,8]To achieve hemihepatic vascular in flow occlusion,dissecting the right/left hepatic pedicle to control the corresponding right/left hepatic artery and portal vein is an important step before liver parenchymal transection.The classical approach involves isolating and dissecting the related branches of the portal vein,hepatic artery,and the hepatic duct outside the liver.[9]After isolation,the relevant hepatic arterial and portal venous branches can be individually controlled.An alternative method of hemihepatic vascular in flow control is to use the"Glissonian" approach.[10-13]This technique is based on the pioneering works of Takasaki et al,and also Launois and Galperin who described thefibrous sheath that envelops the entire portal triad and extends into the liver.[12,14-16]The fusion of the Glisson's capsule with the connective tissue sheaths surrounding the portal vein branches,hepatic artery branches and biliary branches (the portal triad) at the inferior aspect of the liver constitutes the plate system.[17]This plate system consists of the hilar plate above the biliary con fluence,the cystic plate related and above the gallbladder,the umbilical plate above the umbilical portion of the left portal vein[17-20]and the Arantian plate covering the ligamentum venosum.[18-20]The hilar structures can be approached without dissecting the Glisson's sheath to transect the hilar structures.Takasaki et al[12,14]described that in cirrhotic patients,Glisson's sheath identification is even more facilitated by the parenchymal retraction secondary to liverfibrosis.

Hepp and Couinaud[4]described a technique to expose the con fluence of the right and left hepatic pedicles by lifting the quadrate lobe (segment 4b of the liver) upwards and incising the Glisson's capsule at its base.By dissection between the liver substance superiorly and the hilar plate inferiorly,a space could be developed.[21]This technique is referred to as lowering of the hilar plate[18]and it can be carried out safely since it is exceptional (in 1% of case) to have any vascular interposition between the inferior surface of the liver and the hilar plate.Blumgart and Hann[18]recommended this technique to expose the extrahepatic segments of the hepatic ducts,especially the left hepatic duct which runs a long course beneath the quadrate lobe.We used this technique to expose the left and the right hepatic pedicles for laparoscopic hemihepatic vascular in flow occlusion.

The advantages of the Pringle's maneuver are less blood loss and lower blood transfusion rate.[21-27]Several studies[24-27]described different methods.Topal et al[24]made incisions in the liver parenchyma posterior and anterior to the hilum and inserted an endoscopic vascular stapling device under cholangiography guidance.Cho et al[25]described a similar technique,but used laparoscopic hand-assistance to dissect the liver parenchyma above the bifurcation of the right and left hepatic pedicles.Machado et al[26,27]described a technique which was based on small incisions in the liver parenchyma at specific anatomical landmarks to allow a straight forward control of right/left hepatic pedicles with laparoscopic vascular clamps going through the liver parenchyma.These different methods of laparoscopic Glissonian approach by dissecting the liver parenchyma may reduce the time of operation.However,these procedures may cause bleeding from the liver parenchyma,especially in patients with cirrhosis and portal hypertension.Our technique does not need to dissect the liver parenchyma.It can be used in pedicle transection during hemihepatectomy,and in selective clamping for more minor hepatectomies.Our data showed that the hemihepatic vascular in flow occlusion reduced bleeding during liver parenchymal transection.One of our patients who underwent right posterior sectionectomy had a high blood loss because of the large area of liver transection plane.The main limitation of the current study was the small sample size.Overall,the technique is safe,simple and worth further a randomized clinical trial.

Contributors:CYJ and DFW wrote the first draft.ZZJ,CHW,LECH,LQH and LWY analyzed the data.All authors contributed to the design,interpretation and to thefinal draft of the paper.CYJ is the guarantor.

Funding:None.

Ethical approval:Not needed.

Competing interest:No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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