Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

This is a video showing a modified laparoscopic anatomic hepatectomy, which involves the combination of CUSA and ultrasonic dissector in a two-surgeon technique, as well as a modified extracorporeal Pringle maneuver along with low central venous pressure technique. This is a 54-year-old female with the one-week history of liver mass, an increased serum AFP level of 104 nanogram per milliliter. And no other positive lab findings.

Besides the ECG cardiac ultrasound, pulmonary function test showed normal cardiopulmonary function. The magnetic resonance imaging, MRI, indicated a tumor about two centimeter in size located in the S5 and S8 segments of the liver, which was considered primary hepatocellular carcinoma. Statement, this protocol and surgery video demonstration obtained the patient's informed consent before surgery.

And meanwhile, obtained approval from the Fifth Affiliate Hospital of Sun Yat-sen University. Protocol, preoperative preparation. Perform laboratory tests, including blood routine examination, coagulation function test, liver and renal function test, AFP, CEA, and ICG-R15 to evaluate the general condition of the patients.

Perform imaging examinations, including thoracic and upper abdominal CT scans and liver MRI to evaluate tumor location, size, and presence of distant metastasis. Perform ancillary tests, including ECG, cardiac ultrasound, and pulmonary function tests to evaluate the patient's heart and lung condition. Calculate the hepatic volume by CT volumetry calculation.

If patients are considered to perform major hepatic resections, more than two hepatic segments, ensure that the future liver remnant, FLR divide total liver volume, TLV ratio is no less than 40%Ensure that patients fully understand their medical condition and are calm enough to achieve good physical and mental preparation for the operation. Patients inclusion criteria. Both primary and secondary liver malignancies, as well as benign liver disease, requires segmentectomy.

Perform surgery on both male and female aged between 15 to 85 years. Ensure that the patient is in good general condition and can tolerate both anesthesia and laparoscopic hepatectomy. Ensure that the preoperative liver function classification according to Child-Pugh is either A or B.ICG-R15 is less than 10%and FLR divide TLV ratio is no less than 40%Patients exclusion criteria.

Do not include patients with hepatocellular carcinoma with portal and hepatic vein invasion. Do not perform surgery on patients with uncontrolled systemic infection. Do not perform this surgery if severe portal hypertension is diagnosed by preoperative CT or endoscopy.

Ensure that there has been no recent history of gastric or esophageal variceal bleeding as well as refractory ascites. Ensure there is no diffuse intrahepatic metastasis. Or distant metastasis.

Do not perform this surgery in cases where laparoscopic surgery is not feasible due to a history of severe abdominal Adhesions resulting from multiple prior abdominal operations. Surgery, as the preoperative MRI revealed that most of the tumor was located in S5 with a small portion located in the ventral segment of S8 and without any adjacent large blood vessels or bile ducts, we planned to remove S5 plus partial S8 to ensure a wide resection margin for complete tumor removal. Therefore, we intended to ligate both pedicles of S5 and the ventral branches of the S8 pedicles, as well as their branch veins draining into the middle hipate vein.

The depth of resection can be achieved by dissecting the ventral branch of S8 segments and along the hepaticpedicel of S5.Preparation phase. Under general anesthesia, place the patient in a supine position with legs apart and head elevated while feet are lowered, forming a body angle of 30 degree. Reduce the liquid infusion to one milliliter per kilogram per hour, by the anesthetist, to keep the CVP below five centimeter water column during the operation.

Disinfect the abdominal skin with iodine and drape the patient to prepare a sterile field. Ensure that the primary surgeon stands on the right. The secondary surgeon stands on the left.

And the assistant stands between the patient's legs. Insert the trocars according to the location of the tumor. For this patient, establish an observation port by inserting a 10mm trocar one centimeter below the umbilicus.

Position two 12mm trocars bilaterally at the lateral border of rectus abdominis muscle. Two centimeters superior to the umbilicus. Position two 5mm trocars bilaterally below the subcostal margin along the midclavicular line.

Combine with the preoperative MRI findings, locate and reevaluate the tumor with laparoscopic ultrasound. Perform the surgery as planned. Demarcate the resection area.

Locate the first port hepatis and open the omental bursa. Put the cotton rope into the abdominal cavity. Use laparoscopic forceps with an elongated head to horizontally pass the cotton rope through Winslow's foramen.

And encircle the hepatoduodenal ligament. Insert the Lumir device into the cavity to tighten the cotton rope and occlude hepatic inflow. Then secure it with a vascular clamp.

Limit the clamping time to 15 minutes, followed by a five-minute declamping period during the operation. The secondary surgeon opens the liver capsule along the marked border using an ultrasonic dissector while the primary surgeon smashes the hepatic parenchyma using a laparoscopic CUSA in an archeological way. Each of the encountered small blood vessels and bile ducts are cauterized directly with an ultrasonic dissector.

While large ones are divided after being clamped by Hem-o-lok. Dissect the dorsal and ventral branches of the S8 segment within the middle hepatic vein. Clamp and ligate the ventral branch using an Endo-GIA stapler.

While preserving the dorsal branch and dorsal segment of the S8.Dissect the hepatic vein of the S5 segment and divide it after being clamped by Hem-o-lok. Dissect the hepatic pedicle of the S5 segment and cut it with the Endo-GIA stapler. At this point, the planned resection of the liver segments have been successfully completed.

Loosen the cotton rope, cauterize the surgical wound to stop bleeding exactly. Rinse the operation area and drain thoroughly. Cut the cotton rope to remove the Lumir device.

Cover the operation area with a layer of absorbable hemostat. Postoperative follow-up. Adopt the following management to the patients after returning to the general ward.

Monitoring of vital signs, intravenous nutrition, rapid recovery of internal organ functions, prevention of infection and deep venous thrombosis. Provide a full-fluid diet and gradually transition to a regular diet over the next few days. If the patients have no significant discomfort, keep the rest of the treatments unchanged for the first three days.

Perform lab examination of whole blood cells. Liver and kidney function tests, electrolyte levels, blood coagulation function. Additionally, perform early thoracic and abdominal ultrasounds to check for hydrothorax and ascites.

Perform a plain upper abdominal CT scan to confirm the absence of residual tumor bleeding and bile leakage. And then remove the drain. Once drainage fluid is minimum and clear.

Which is typically five to six days post-operation. Patients are typically discharged from the hospital one week after surgery, and return to the outpatient clinic one month later. If necessary, surgeons may take appropriate measures and extend the course of treatment according to the patient's condition.

Representative results. Post-surgical CT imaging showed no residual liver tumor and the pathological result indicated primary hepatocellular carcinoma with a negative resection margin. Since 2020, the CUSA-ultrasonic dissector-extracorporeal Pringle maneuver technique has been routinely carried out in our center.

And a total of 108 patients were treated by this means. Here we retrospectively analyzed 10 patients who received this procedure between July and August in 2021. The median age of these patients was 53.8 years.

They underwent either segmentectomy or subsegmentectomy, and received an average of 3.5 times of extracorporeal Pringle maneuver during the operation. The operation time and estimated blood loss were fairly good. No patients suffered major intraoperative and postoperative complications.

And there were no perioperative deaths. The final histopathological results of all patients were hepatocellular carcinoma. Conclusion, this technique is both safe and feasible.

It is easier to achieve a dry and clean operative field so the bile ducts and blood vessels can be ligated and dissected accurately. Postoperative complications, such as hemorrhage and biliary leakage are effectively reduced. Wide resection margin can also be guaranteed in this technique.

This method is expected to be a promising surgical technique for patients who receive LAH.