LAPAROSCOPIC HEPATIC S5-6 SEGMENTECTOMY FOR BLEEDING HCC

Acute bleeding combined with spontaneous rupture of hepatocellular carcinoma (HCC) has low incidence (less than 3%), but it remains a life-threatening condition and it could lead to an ‘‘emergency liver resection’’. Liver resection performed between the initial admission and following an initial medical/inter- ventional management of 72 h is considered in most centers as an ‘‘emergency liver resection.’
If years ago emergency laparotomy was the standard treatment, with mediocre outcomes, in terms of intra and postoperative mortality and long-term survival, to date interventional arterial embolization and mininvasive surgery rapresents valide, safe and effective treatment.
We present a video of laparoscopic bisegmentectomy (SV-SVI) for a bleeding HCC with hemoperitoneum.

In case of active bleeding at the CT angiography, interventional arterial embolization (TAE) remains the treatment of reference for patients with a bleeding HCC, whether stable, stabilized by resuscitation, or persistently unstable. Open surgical hemostasis is considered as a second-line treatment when TAE failed or in case of portal vein occlusion. Emergency liver resection is usually considered for non-cirrhotic/Child A class patients without evidence of high portal hypertension levels.
We believe that for patients who have no evidence of active bleeding and are hemodynamically stable enough to complete diagnostic workup, a minimally invasive procedure such as laparoscopy in a deferred emergency setting is a safe and definitive treatment.

While laparoscopic liver resection is generally considered safe and effective, there are some contraindications that may make this procedure unsuitable for certain patients. Some of the contraindications to laparoscopic liver resection for HCC may include: advanced cirrhosis, large tumors, abnormal liver anatomy, coagulation disorders. These contraindications may be exacerbated by active bleeding of the lesion and the emergency setting. In any case, it is the experience of the individual center that determines the feasibility of the procedure.

- THUNDERBEAT® (TB) (Olympus Medical Systems Corp): a dynamic energy system device that simultaneously delivers ultrasonically generated frictional heat energy and electrically generated bipolar energy. It can offer a safe, reliable and substantially rapid liver resection particularly in patients with normal or near-normal liver parenchyma.
- Laparoscopic intraoperative ultrasound: is an extremely cheap, safe and valuable diagnostic tool. Intraoperative ultrasound is considered the gold standard for the diagnostic process during liver procedures
- CUSA® Excel+ System, Ultrasonic Surgical Aspirator System: CUSA itself can divide the liver parenchyma as well as keeping the operative field dry by suctioning; it can limit bleeding, while preserving vessels
- Aquamantys® bipolar sealer, that combine radiofrequency (RF) energy and saline to provide hemostatic sealing of soft tissue without smoke or char. It is feasible and safe and allows to achieve almost bloodless parenchymal division with minimal necrosis and negative margins even in atipycal resection.

We used a supine straight split-leg position, affectionately termed the “French position”. This position allows a surgeon to stand between the patients’ legs, in a more ergonomical standing positions. The upper limbs are typically extended to allow for more lateral trocar placement, as well as to add stability to the patient’s position during left-right axis tilting.

Our workup included an urgency CT scan, to exclude an active bleeding liable to TAE, and subsequent abdominal MRI, to complete our diagnosis. Magnetic resonance imaging (MRI) is the modality of choice for liver imaging due to its superior contrast resolution in comparison with computer tomography and the ability to provide both morphologic and physiologic information. Usually an emergency setting exclude MRI, due to the prolong time requested to its performance.

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The authors have stated explicitly that there are no conflicts of interests in connection with this article.

- Schwarz L, Bubenheim M, Zemour J, et al. Bleeding Recurrence and Mortality Following Interventional Management of Spontaneous HCC Rupture: Results of a Multicenter European Study. World J Surg. 2018;42(1):225-232. doi:10.1007/s00268-017-4163-8
- Darnis B, Rode A, Mohkam K, Ducerf C, Mabrut JY. Management of bleeding liver tumors. J Visc Surg. 2014;151(5):365-375. doi:10.1016/j.jviscsurg.2014.05.007