Caudal Approach to Pure Laparoscopic Posterior Sectionectomy Under the Laparoscopy-specific View

Aim: To study our novel caudal approach laparoscopic posterior-sectionectomy with parenchymal transection prior to mobilization under laparoscopy-specific view.

Methods: Points of the procedure are: (1) Patients are put in left lateral position and posterior sector is not mobilized; (2) Glissonian pedicle of the sector is encircled and clamped extra-hepatically and divided afterward during the transection; (3) Dissection of inferior vena cava (IVC) anterior wall behind the liver is started from caudal. Simultaneously, liver transection is performed to search right hepatic vein (RHV) from caudal; (4) Liver transection proceeds to the bifurcation of the vessels from caudal to cranial, exposing the surfaces of IVC and RHV. Since the remnant liver sinks down, the cutting surface is well-opend; and (5) After the completion of transection, dissection of the resected liver from retroperitoneum is easily performed using the gravity. This approach was performed for a 63 years old woman with liver metastasis close to RHV.

Results: RHV exposure is required for R0 resection of the lesion. Although the cutting plane is horizontal in supine position and the gravity obstructs the exposure in the small subphrenic space, the use of specific characteristics of laparoscopic hepatectomy, such as the good vision for the dorsal part of the liver and IVC and facilitated dissection using the gravity with the patient positioning, made the complete RHV exposure during the liver transection easy to perform. The operation time was 341 min and operative blood loss was 1356 mL. Her postoperative hospital stay was uneventfull and she is well without any signs of recurrences 14 mo after surgery.

Conclusion: The new procedure is feasible and useful for the patients with tumors close to RHV and the need of the exposure of RHV.