Laparoscopic hepatectomy

Laparoscopic hepatectomy

The indications for hepatectomy are the same whether done by open or laparoscopic technique. It should be emphasized that laparoscopic hepatectomy is a complex procedure and requires expertise both in laparoscopic techniques and open liver resections. Most importantly, understanding intraoperative anatomy is critical to avoid biliary or vascular injuries. The selection for candidates for laparoscopic liver resection is based on tumor location, size, and number. With regard to location, the lesions located in the anterolateral segments (II to VI) are considered safe areas for the laparoscopic approaches. Lesions located in segment VII, VIII, IV-A, and I or the caudate lobe remain technically difficult because of the proximity of the inferior vena cava (IVC) and the hepatic veins. Management of malignant liver tumors should not differ from open surgery. Importantly, laparoscopic liver surgery is merely an adjunct or tool in hepatic surgery. As such, the guiding principles of hepatic surgery should always be maintained whether done open or laparoscopically. In general, laparoscopic liver surgery is reserved for patients with small tumors (less than 5 cm) located in favorable anatomic locations within the liver. Except for exophytic lesions, which are located on the edge of the liver, a laparoscopic approach is not recommended for lesions greater than 5 cm. This is especially true when tumors are situated near the inflow or outflow vascular structures. Large intrahepatic tumors are challenging laparoscopically because of the difficulty in mobilization, increased risk for hemorrhage, and a margin-positive resection. The range of resections that can be done laparoscopically is wide and includes single wedge resections, multiple bilobar resections, anatomic segmental resections, formal hemihepatectomy, and extended resections. The main determinant for pursuing a laparoscopic approach should be based on surgeon training, experience, and their comfort level.

Special equipment

Laparoscopic liver resections require state-of-the-art equipment. Two high-volume carbon dioxide insufflators are needed because these procedures generate excessive vapor, smoke, and bleeding that require frequent suctioning. Operating rooms should be equipped with high-resolution display monitors, camera equipment, laparoscopic booms, and specialized beds capable of achieving extreme position angles ( Fig. 4.1 ).

These procedures tend to be equipment intensive, often requiring multiple thermal generators, ultrasound, and other bulky machines, depending on the procedure. The setup of laparoscopic liver procedures uses multiple disposable and nondisposable instruments. The general surgical instruments table is maintained away from the patient due to the frequent table movements and patient repositioning. A Mayo stand is useful to help organize and secure instruments for ease of access. Typical instruments used for laparoscopic liver procedures include a high-power suction irrigator, multiple thermal energy devices, and a flexible-tip ultrasound probe ( Fig. 4.2 ).

In addition to high-resolution monitors, high-definition flexible-tip cameras can improve visualization of the posterior liver and dissection of the hepatic veins. We prefer to use the 45-degree fixed scope, which provides a stable view and allows excellent visualization throughout the abdomen. Strong adjustable atraumatic retractors are needed to support the large size, weight, and volume of the liver. Specialized vascular equipment is available, which includes laparoscopic Satinsky clamps, corrugated flexible and reusable ports, and vascular bulldog clamps ( Fig. 4.3 ).

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