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Right Hepatic Lobectomy with Intraparenchymal Vascular Control

Contributors: Amy D. Lu and Diego Di Sabato

A right hepatic lobectomy with laparoscopic mobolization and division of the short hepatic veins and intraparenchymal division of the vasculature is depiected in this video.

Editor Recruited By: Jeffrey Matthews, MD

DOI: http://dx.doi.org/10.17797/i04zpfb2x3

Adenomas are benign tumors of the liver. However, they may become malignant and larger ones have the potential to bleed. If the patients are on hormones, such as birth control, the medications are stopped to see if there is regression of the lesion. Small adenomas are usually monitored and do not need surgical intervention. This is a 26 year old female patient with normal liver function found to have a 6 cm adenoma that was arising in the posterior medial aspect (segment 7 and 8) of the right lobe. The patient with a BMI of 23 was placed in the supine position in reverse Trendelenberg. With larger BMI patients, sometimes they are placed in lithotomy so that the camera person can stand in the middle.
Adenomas may become symptomatic causing pain or bleeding. In this case, this patient's adenoma continued to grow off birth control and the radiologic imaging changed and was suspicious for malignancy.
In doing a formal right hepatectomy, there is removal of 60% or so of the liver. The volume of the remaining remnant is usually sufficient. However, if there is disease in the liver (eg. NAFLD, NASH or fibrosis) there may not be sufficient liver volume remaining, especially if the patient suffered a post-operative complication of infection.
The patient is in the supine position in reverse Trendelenberg for the laparascopic portion of the procedure. When the patient is large, sometimes it is beneficial for the patient to be in lithotomy so that the camera surgeon can stand in the center.
The patient usual presents with some radiologic imaging. The size of the lesion and location of the lesion determine the amount of liver removed and whether it is feasible to do the procedure laparoscopically. We are usually able to assess for any aberrant vascular anatomy on the scan. Using the CUSA technique, it takes a little longer but it is easier to control for bleeding. The small vessels can be cauterized with the CUSA bovie attachment or using endoclip appliers may be ligated. The larger vascular pedicle is transected using endovascular stapler. In acute bleeding, with a gelport in place, the hand can be used to apply pressure to control hemorrhage if need be.
For right lobe liver resections, we utilized a laparoscopic hand approach in order to mobilize the right lobe completely to the vena cava and also ligate extraneous short hepatic veins. The advantage is to minimize the incision to a vertical midline. A pure laparoscopic approach can be done, but since an incision is needed to remove the portion of liver, using a gelport and hand assisted approach shortens the time of the surgery. Intraparenchymal ligation of the vessels prevents injury to the adjacent bile duct or hilar structures in the porta hepatis. However, the disadvantage of this is there is vascular inflow to the liver during transection of the parenchyma.
The major concern in this procedure is bleeding, specifically, while mobilizing the right lobe to the level of the vena cava and transection of the short hepatic veins. Intraparenchymal transection of the portal vein avoids accidental injury of the main portal vein or remaining left portal because there is no extrahepatic dissection of the porta hepatis. Other intra-operative complications include injury to the bile duct or hepatic artery. To avoid these complications, it is also better to perform intraparenchymal transection then extrahepatic dissection in the porta hepatis, so as not to develop strictures postoperatively or even vascular thrombosis because of vessel injury. With regards to the bile ducts, there may be a leak from the cut surface of the liver postoperatively. A JP drain is placed in the bed of the resection to evaluate and drain any possible leaks. The leaks should seal post-operatively. Some may perform ERCP with stenting to better evaluate the leak and to aid in decreasing the amount of leak.
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