Laparoscopic resection of liver segments V and VIII for colorectal metastasis

Laparoscopic liver resection in selected patients in highly specialized centers provides comparable oncological results to treatment with open liver resection for patients with colorectal liver metastases. In this video, we present the case of a patient who underwent the resection of two liver segments in the context of a colorectal pathology. Initially, this lesion was estimated as sitting in the liver’s segment IV, but using a specific software dedicated to reconstructions of CT-scan data, it was discovered that this lesion was situated across segment V and segment VIII. This reconstruction allows to obtain a perfect visualization of the different relationships between the vessels and also allows to guide the procedure and to simulate the operative maneuver.

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Laparoscopic resection of liver segments V and VIII for colorectal metastasis

Authors

B Dallemagne, D Mutter, L Soler, J Marescaux

Abstract

Laparoscopic liver resection in selected patients in highly specialized centers provides comparable oncological results to treatment with open liver resection for patients with colorectal liver metastases. In this video, we present the case of a patient who underwent the resection of two liver segments in the context of a colorectal pathology. Initially, this lesion was estimated as sitting in the liver’s segment IV, but using a specific software dedicated to reconstructions of CT-scan data, it was discovered that this lesion was situated across segment V and segment VIII. This reconstruction allows to obtain a perfect visualization of the different relationships between the vessels and also allows to guide the procedure and to simulate the operative maneuver.

Keywords

Laparoscopic resection, liver segment V, liver segment VIII, colorectal metastasis

Media type

Surgical video

Duration

10'13''

Publication

2009-10

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E-publication

WeBSurg.com, Oct 2009;9(10).
URL: http://www.websurg.com/doi-vd01en2689.htm

Laparoscopic resection of liver segments V and VIII for colorectal metastasis

1. Clinical case presentation 00'11''

In this video, we present the case of a patient who underwent the resection of two liver segments in the context of a colorectal pathology. In 2005, this patient was operated upon for a rectal adenocarcinoma, which was preceded by a neoadjuvant chemotherapy. In November 2006, he underwent a right hemicolectomy for a degenerated polyp and in the follow-up, a tumoral lesion was found at the level of segment IV of the liver.

2. Lesion identification: usefulness of CT-scan reconstruction 00'40''

Initially, this lesion was estimated as sitting in the liver’s segment IV, but using a specific software dedicated to reconstructions of CT-scan data, it was discovered that this lesion did not affect segment IV, but was in fact situated across segment V and segment VIII. This reconstruction allows to obtain a perfect visualization of the different relationships between the vessels. It also allows to guide the procedure and to simulate the operative manoeuvre: this is especially helpful to assess the residual volumes. In the current case, the volume is significant so that the software is not mandatory, but it does provide a good appreciation in the event of much more enlarged liver resections. It is based on this preoperative evaluation that the procedure will be guided.

3. Identification of main vascular structures 01'46''

The first operative step is to identify the major vascular structures, and especially the right and median suprahepatic veins in order to determine the division plane.

4. Intraoperative ultrasonography 02'00''

This is achieved through the intraoperative ultrasonography, which also helps to identify and measure the lesion, and evaluate the safety margins that must be preserved by all means. In this patient, we observe that it is necessary to perform a liver resection of the segment V, as well as a portion of segment VIII. The procedure starts with the mobilization and the dissection of the cystic pedicle since the gallbladder will be removed. Based on the preoperative reconstruction, we had learnt that the portal branch draining the right anterior sector considered for the resection could be accessed.

5. Hepatic pedicle dissection 02'46''

This led to the initial vascular approach, with dissection of the hepatic pedicle structures and identification of these vascular branches that drain electively into the liver segments V and VIII. The dissection of the hepatic pedicle is carried out conventionally. The elements of the cystic pedicle will be clipped and divided in order to allow access to the different structures of the hepatic pedicle and especially when they drain towards the anterior segments of the liver. The cystic pedicle is clipped. This clipping facilitates the mobilization of the hepatic pedicle, and especially the dissection of the posterior structures. A loop is placed, not to identify structures but to help with the retraction during the dissection of the portal vein’s structures. Dissection is carried out towards the right portal branch. At this level, the portal branch of the liver’s anterior segments is progressively identified. This branch is dissected in a selective fashion. At this moment in the procedure, a laparoscopic clamp can be readied to clamp the portal vein in case of lesion during its dissection: this is an important safety measure.

6. Portal vein occlusion test 05'46''

Once identified, a loop is placed around the portal vein and an occlusion test is performed in order to analyze the vascularization of the concerned liver segments.

7. Demarcation of liver segments 06'18''

Here we can see that there is a visible demarcation between the segments whose vascular supply has been clamped. The dissection itself is orientated by the median suprahepatic vein’s plane.

8. Hepatic dissection with Ligasure device and bipolar forceps 06'43''

The dissection and hemostasis of the first few centimetres of the hepatic parenchyma are performed with the 5mm Ligasure device. This instrument allows to perform a crushing of the parenchymal structures with a concomitant hemostasis. Additional coagulating touches are performed with bipolar forceps. This two-handed technique with bipolar instruments seems rather interesting, more so than another technique using a bipolar forceps and scissors. The first vascular control allows us to keep a very clean operative field, which increases the chances of identifying the various vascular and biliary structures at the level of the parenchyma. The small vascular and biliary structures are controlled by applications of the Ligasure device.

9. Endo-GIA linear stapler application 07'42''

The larger structures, around 3 to 4mm, are controlled by applying clips and the portal elements are controlled with applications of vascular Endo-GIA linear staplers. The problem with this type of resection is to preserve the vascular branches of the liver’s posterior segments, which can be seen on the inferior section of this picture. Segment V’s portal pedicle is controlled by applying a vascular Endo-GIA. This procedure is performed without vascular control of the hepatic pedicle but essentially with the elective control that had been performed at the beginning of the procedure. The portal branch of the segment VIII is also controlled with the application of the Endo-GIA and following this resection, orientated applications of bipolar coagulation allow to obtain a perfectly vascularized division line with no hemorrhages.

10. TachoSil® application 09'22''

We apply a TachoSil® at the heart of the resection in order to control the larger biliovascular pedicles. At the end of the procedure, we can see the position of the right suprahepatic vein that has been preserved. A simple drain with no suction is placed.

11. Specimen extraction 09'47''

The hepatic resection specimen is introduced into an extraction bag along with the gallbladder. The bag is then removed through the abdominal wall by enlarging the trocar site situated at the level of the left hypochondrium. The pathological findings confirm that this is a 4cm tumor of colorectal origin with good safety margins.