Laparoscopic Liver Resection

Rong Liu
Laparoscopic
Liver Resection
Theory and Techniques
123
Laparoscopic Liver Resection
Rong Liu
Laparoscopic Liver
Resection
Theory and Techniques
Rong Liu
Surgical Oncology
Chinese PLA General Hospital
Beijing, China
ISBN 978-94-017-9734-4 ISBN 978-94-017-9735-1 (eBook)

https://doi.org/10.1007/978-94-017-9735-1
Library of Congress Control Number: 2017953440
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Preface
Since the first laparoscopic cholecystectomy was performed in 1987, almost 30

years have elapsed. Although laparoscopic technique had been gradually applied in
almost every area of surgery, laparoscopic liver resection (LLR) underwent a slow
development all over the world since the first case was performed in 1991, espe-
cially in the first decade, mainly due to sophisticated anatomy, risk of bleeding, lack
of ideal instrument, and concern for adequate margins in resection of malignant
tumors. As a result, there were only a few cases of LLR performed, most of which
were resections of solid tumor limited in the left lateral section or the margins and
cystic fenestration, and the feasibility and efficiency of LLR had been questioned.
We have been performing LLR since 2001 and reported the first case of laparo-
scopic hemihepatectomy, laparoscopic right trisegmentectomy, laparoscopic mod-
eling left lateral sectionectomy, single-incision laparoscopic liver resection, and
retroperitoneal laparoscopic liver resection in China or all over the world. Based on
those experiences, we established our unique technique and theory system of ana-
tomic laparoscopic liver resection, which is characterized by precontrol of the blood
supply of the to-be-resected area and prevention of bleeding, and have performed
over 1000 cases of laparoscopic liver resection to date.
Benefiting from technique development and experience accumulation, in the
recent 10 years, the application of minimally invasive technique in hepato-pancre-
ato-biliary surgery had underwent rapid development, and LLR has been generally
accepted after the Louisville Statement was announced in 2008. According to the
literature, more than 3000 cases of LLR have been reported worldwide by 2014,
and 50% of them were applied for malignant lesions. Not only the number of LLRs
but also the ratio of major liver resections increased, and LLR for lesions in every
segment was reported. The location of lesions was no longer considered as a con-
tradiction for LLR anymore, and it was generally accepted that minimally invasive
surgery has advantages such as smaller local trauma, milder systemic reactions,
less operative blood loss, shorter hospital stay, lower morbidity, and better cos-
metic results.
Despite all the achievements above, minimally invasive surgery is still not the
majority of operations in hepato-pancreato-biliary surgery until now, not only in
China but all over the world, and the technique varies from center to center, leading
to difficulty in popularization. Thus, based on the experience of our LLR cases and
the modeling or stylized surgery idea, we wrote this book, with plenty of pictures
v
vi Preface
that demonstrate the operative and technical details presented, hopefully, to serve as
reference and thus facilitate other centers to perform minimally invasive surgery.
As the first English book of our team, we do know that there are still some limita-
tions of this book, and we are more than glad to receive judgments from peers all
over the world, to make this book better and benefit more patients. Also, we will
publish books focusing on laparoscopic pancreatectomy and robotic hepato-pancre-
ato-biliary surgery, which will overcome the known difficulties during writing this
book and hopefully be better.
On behalf of all the surgeons in our team, I would like to express my sincere
acknowledgment to Academician Wu Mengchao and Academician Huang Zhiqiang,
who are my mentors and had been supporting and guiding our team to perform
minimally invasive surgery. We also would like to thank all the colleagues from the
Department of Anesthesiology, Department of Nursing, Department of Intensive
Care Unit, Department of Radiology, and so on, who helped us a lot to perform the
surgeries. And thanks to all the patients, for trusting us and for being supportive to
our writings.
Beijing, China Rong Liu

Contents
1 Laparoscopic Anatomical Hepatectomy. . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 What is LAH? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Why Choose LAH?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.3 Key Issues and Technique Details. . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.3.1 Identification of Portal Pedicles and
Root of Hepatic Vein. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.3.2 Prevention of Bleeding and Hemostasis . . . . . . . . . . . . . . . . 11
1.3.3 Parenchymal Dissection and Exposure
of Hepatic Vein. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.3.4 Intraoperative Navigation. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2 Patient Positioning and Ports Placement . . . . . . . . . . . . . . . . . . . . . . . . 19
2.1 Patient Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.1.1 The First Position: Reverse Trendelenburg Position. . . . . . . 19
2.1.2 The Second Position: Lithotomy Position. . . . . . . . . . . . . . . 19
2.1.3 The Third Position: Left Lateral Decubitus Position. . . . . . . 20
2.2 Principle of Trocar Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.2.1 Left Lateral Lobectomy and Left Hemihepatectomy. . . . . . 22
2.2.2 Right Posterior Lobectomy . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.2.3 Right Hemihepatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3 Preoperative Preparation and Anesthesia for Laparoscopic
Liver Resection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.1 Preoperative Evaluation of Patients. . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.1.1 Imaging Examination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.1.2 Systemic Organ Function Evaluation . . . . . . . . . . . . . . . . . . 26
3.2 Anesthesia in Laparoscopic Liver Resection. . . . . . . . . . . . . . . . . . . 28
4 Laparoscopic Liver Cysts Fenestration . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.1 Indications and Contraindications. . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.1.1 Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4.1.2 Contraindication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4.2 Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
4.3 Key Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
vii
viii Contents
4.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

4.5 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
5 Laparoscopic Partial Hepatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5.1.1 Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5.1.2 Contraindications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5.2 Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5.2.1 Patient’s Position and Trocar Placement. . . . . . . . . . . . . . . . 36
5.2.2 Laparoscopic Exploration . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
5.2.3 Partial Hepatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
5.2.4 Hemostasis and Drainage. . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
5.3 Major Operating Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
5.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
5.4.1 Intra-Operative Hemorrhage . . . . . . . . . . . . . . . . . . . . . . . . . 41
5.4.2 CO2 Embolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5.4.3 Biliary Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5.5 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
6 Laparoscopic Single-Site Hepatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . 45
6.1 Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
6.2 Steps and Key Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
6.3 Advantages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
6.4 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
6.5 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
7 Laparoscopic Left Lateral Sectionectomy . . . . . . . . . . . . . . . . . . . . . . . 51
7.1.1 Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
7.2 Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
7.2.1 Patient Position and Trocar Distribution. . . . . . . . . . . . . . . . 52
7.2.2 Exploration and Mobilization . . . . . . . . . . . . . . . . . . . . . . . . 52
7.2.3 Rough Dissection of the Portal Pedicles
of Segments 2 and 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
7.2.4 Transection of the Portal Pedicles
of Segments 2 and 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
7.2.5 Dissection of the Deep Parenchyma to Expose LHV . . . . . . 55
7.2.6 Transection of the Left Hepatic Vein. . . . . . . . . . . . . . . . . . . 55
7.2.7 Hemostasis and Drainage. . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
7.2.8 To Withdraw Specimen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
7.3 Key Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
7.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
7.5 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Contents ix
8 Laparoscopic Left Hepatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

8.1.1 Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
8.2 Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
8.2.2 Exploration and Mobilization . . . . . . . . . . . . . . . . . . . . . . . . 60
8.2.3 Dissection of First Hilum and Control
of Inflow Blood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
8.2.4 Exposure of Second Hilum and Control
of Outflow Blood. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
8.2.5 Parenchymal Dissection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
8.2.6 Transection of LHV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
8.2.7 Hemostasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
8.2.9 Drainage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
8.3 Key Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
8.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
8.5 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
9 Laparoscopic Right Posterior Sectionectomy. . . . . . . . . . . . . . . . . . . . . 67
9.1.1 Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
9.2 Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
9.2.2 Exploration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
9.2.3 Mobilization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
9.2.4 Dissection and Control of Inflow Blood . . . . . . . . . . . . . . . . 69
9.2.5 Control of Outflow Blood . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
9.2.6 Hemostasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
9.2.8 Drainage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
9.3 Key Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
9.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
9.5 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
10 Retroperitoneal Laparoscopic Hepatectomy. . . . . . . . . . . . . . . . . . . . . 73
10.1 Indications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
10.2 Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
x Contents
11 Laparoscopic Right Hepatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

11.2 Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
11.2.1 Patient’s Position and Trocar Arrangement. . . . . . . . . . . . . . 78
11.2.2 Laparoscopic Ultrasonography . . . . . . . . . . . . . . . . . . . . . . . 79
11.2.3 Mobilization of the Right Lobe. . . . . . . . . . . . . . . . . . . . . . . 79
11.2.4 Control of the Inflow/Outflow Vessels. . . . . . . . . . . . . . . . . . 80
11.2.5 Transection of the Hepatic Parenchyma . . . . . . . . . . . . . . . . 81
11.2.6 Specimen Retrieval and Drainage. . . . . . . . . . . . . . . . . . . . . 85
11.3 Key Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
11.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
11.5 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
12 Laparoscopic Caudate Lobectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
12.2 Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
12.2.1 Laparoscopic Hepatectomy of Spiegel Lobe. . . . . . . . . . . . . 90
12.2.2 Laparoscopic Hepatectomy of Caudate Process . . . . . . . . . . 93
12.3 Key Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
12.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
12.5 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
13 Radiofrequency Ablation Assisted Laparoscopic Hepatectomy. . . . . . 95
13.2 Steps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
13.3 Key Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
13.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
13.5 Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Laparoscopic Anatomical Hepatectomy
1
Abstract
Over the past 20 years, laparoscopic liver resection (LLR) has gone through a
stirring process of innovation, development, and exploration. LLR nowadays is
almost as important as OLR,. As an evolving surgical technique, LLR has its own
inherent problems too. Laparoscopic anatomical hepatectomy (LAH), instead of
laparoscopic regular hepatectomy, according to our experience, stands for the
laparoscopic regional resection of hepatic tumor or hepatic segment(s), based on
the regional control of blood supply. In this chapter, we will discuss what is
LAH, its advantages and disadvantages and some key techniques.
Over the past 20 years, laparoscopic liver resection (LLR) has gone through a stir-
ring process of innovation, development, and exploration (Fig. 1.1). In some resec-
tions (e.g., hepatic left lateral lobectomy), LLR is even expected to replace open
liver resection (OLR) to become the gold standard procedure, just as laparoscopic
cholecystectomy once did (Chang et al. 2007). Upon the whole, LLR nowadays is
almost as important as OLR, with obvious superiorities including less blood loss
and shorter length of hospital stay.
According to our experience, there are three key factors worthy of more atten-
tion in current practices: appropriate selection of indications and patients, full
understanding of surgical instruments, and standardization of the procedure
(Dagher et al. 2009).
As an evolving surgical technique, LLR has its own inherent problems even with
the impressive improvement in the instruments and clinical experience. The wholly
new surgical perspectives, pneumoperitoneum environment, special operative
instruments, and other features together indicate that LLR might have its unique
regularities different from those of OLR. The surgical experience of performing
OLR can not help the surgeons to perform LLR directly. In some cases, the shackle
of the old concept in OLR might lead to disastrous consequences in LLR. It is rea-
sonable to adopt more stringent indications in LLR than in OLR. The size and
© Springer Science+Business Media B.V. 2017 1

R. Liu, Laparoscopic Liver Resection,
https://doi.org/10.1007/978-94-017-9735-1_1
2 1 Laparoscopic Anatomical Hepatectomy
250
200 191
172
150
124
135
96 96
100
58 84 88
44 78
50 32
27 27
22 40
11
7 10 10 8
0
1996 2001 2006 2011 2016
Fig. 1.1 The dramatically increased number of literatures about LLR
location of a liver tumor, and its spatial relationship with the liver hilum, major
hepatic vessels and inferior vena cava, should be carefully reviewed before surgery.
If a clear transection plane can be determined laparoscopically, LLR is preferred.
Tumor size alone has not been the contraindication of LLR anymore. However, the
choice between LLR and OLR should not change the consequent size of resection
distinctly. Laparoscopic right hepatectomy resection is relatively easier than right
posterior sectionectomy (Segments 6+7). If right posterior sectionectomy is suffi-
cient for the lesion, open surgery should be adopted rather than laparoscopic right
hepatectomy resection.
The newly published international consensus has given a panoramic understand-
ing of this issue (Wakabayashi et al. 2015). Due to the lack of the tactile sensation,
the cutting planes of liver resection were mainly determined by the preoperative
imaging, landmark of the liver, and intraoperative navigation, rather than the hands
of surgeons. Just like two sides of a coin, theoretically, LLR has advantages in surgi-
cal oncology for its essence of "no-touch” techniques. The full assessment of its
surgical and oncological long-dated outcomes is still in progress. On the other hand,
the advanced surgical instruments have played a much more important role in LLR
than OLR. OLR could be performed using the simple crush-clamp technique with-
out any energy device. The whole history of LLR has progressed on the basis of
improvement of various energy equipments and stapling apparatuses. Laparoscopic
surgeons must have full knowledge of the strength and limitations of tools available.
This is the key to give full play to the devices and to avoid any unwanted
complication.
Meanwhile, there exists a high imbalance in the practice of LLR geographically
and individually. Some leading surgeons have already successfully completed the
anatomically accurate segmentectomy of all the Couinaud segments, which almost
eliminated the absolute technical contraindications of LLR (Ishizawa et al. 2012).
In most of the other hospitals, LLR remains to be a technically challenging surgery
1.1 What is LAH? 3
and the peripheral non-anatomic liver resections are more preferred to perform lapa-
roscopically. LLR has not become a standardization operation, because the compli-
cations may be more difficult to control laparoscopically than the procedure itself.
The relative contraindications of LLR are changed with the advances of surgeons'
techniques. There is still a long way to achieve the standardization and promotion of
LLR.
1.1 What is LAH?
Laparoscopic anatomical hepatectomy (LAH), instead of laparoscopic regular hep-

atectomy, according to our experience, stands for the laparoscopic regional resec-
tion of hepatic tumor or hepatic segment(s), based on the regional control of blood
supply (Fig. 1.2), which is more technical complicated than open anatomical hepa-
tectomy. Generally speaking, it means a surgical idea that we have to control the
blood supply before resection of the tumor. For regular resection, LAH means effec-
tive inflow and outflow blood control before resection, and for irregular resection, it
means effective feeding vessel control before resection.
LAH often requires more special techniques. To better expose the target region
and critical anatomic structure of the liver, the patient position and trocar distribu-
tion should be arranged jointly and flexibly, which leads to a series of innovations
such as trans-thoracic LAH (Hallet et al. 2015) and retroperitoneal LLR (Hu et al.
2011). Laparoscopic intraoperative ultrasonography is important for laparoscopic
anatomical hepatectomy, especially for those less experienced surgeons, which is
the last chance for a surgeon to confirm the intrahepatic structure before paren-
chyma dissection, including the location of the tumor and its spatial relationship
with the major hepatic vessels, tumor-bearing portal pedicles, and landmark hepatic
vein.
Anatomical hepatectomy (AH) has three technique characteristics: identification
and transection of the portal pedicle, ischemic line-guided parenchyma dissection,
and full exposure of related hepatic vein in the raw surface of the remnant liver. It is
generally believed that REAL anatomical hepatectomy should possess these three
features indispensably.
In our opinion, the three characteristics are not identical in terms of their impor-
tance. Identification and transection of the portal pedicle is the most fundamental
step for anatomical hepatectomy, and usually constitutes the basis for the other two
characteristics. Only if the portal pedicle is identified, the subsequent ischemic line
could be revealed. The process of hepatic vein exposure is essential to the establish-
ment of the cutting plane and parenchyma dissection. This is the most essential
characteristic of anatomical hepatectomy.
With the understanding of the above, the concept of LAH could be expanded, with
the main focus on the extent of resection, besides complete resection of the Couinaud
segments and their combination. Wakabayashi brought up “laparoscopic limited ana-
tomical resection” (Yoon et al. 2013), and used the limited anatomic sub-segmental
resection to replace the central bisegmentectomy. The merits of LAH, such as less
Fig. 1.2 The scheme of

LAH
blood loss and clear cutting boundaries, have been inherited, while more normal liver
parenchyma is preserved. Takahashi defined the subunit of Couinaud segments as a
cone unit (Yamamoto et al. 2014). Each cone unit contains a single tertiary Glissonean
branch and its territory parenchyma. Couinaud segments consist of three or four cone
units. The idea deepened the understanding of the nature of LAH. Actually, exposure
of the hepatic vein may be adopted by non-anatomic partial hepatectomy to guaran-
tee the enough margin in LLR (Yoon et al. 2013).
According to our practical experience, to expose the full landmark hepatic vein is
relatively demanding than identification of the portal pedicle and parenchyma dissec-
tion. If those surgeons with less experience recklessly dissect the parenchyma around
the main hepatic vein, uncontrollable bleeding might be caused, which is more dif-
ficult to fix by the same surgeon laparoscopically. There essentially exist some
1.2 Why Choose LAH? 5
compromises due to the level of current laparoscopic surgical practice. In fact, suf-
ficient margin may play a more important role than exposure of the entire hepatic
vein.
LAH should be a clinically feasible and flexible strategy, rather than to just find
the boundaries and root according to the Couinaud liver segments. Laparoscopic
anatomic hepatectomy is not equivalent to laparoscopic segmental resection or all
sorts of their combination.
1.2 Why Choose LAH?
The role of LAH is built on its surgical and oncological values.

LAH could reduce intraoperative blood loss, decrease the incidence of post-
operative biliary leak and other complications, minimize the loss of normal liver
tissue, accelerate postoperative recovery, and provide the possibility of repeated
liver resection. The parenchyma dissection by LAH is accompanied with a lin-
ear “vessel- less” plane. This decreases the injury possibility of the small
branches of artery, portal vein, and bile duct. The irregular multidimensional
transection plane of the non-anatomic liver resection could cause more unpre-
dictable vessel injuries. Through a segment-based liver resection and its vari-
ants, we could preserve as much normal parenchyma as possible while ensure a
enough surgical margin. The adequate margin is the key to prevent tumor recur-
rence, while enough liver preservation contributes a lot to postoperative recov-
ery, especially for those with liver cirrhosis. LAH also causes less postoperative
abdominal adhesions. Once tumor relapse occurs, repeated LAH could be per-
formed. Most importantly, LAH can be used for tumors located at any region
only if it is suitable for resection as discussed above, including those centrally
located tumors (Yoon et al. 2013).
The patients of hepatocellular carcinoma (HCC) benefit markedly from anatomic
hepatectomy oncologically. HCC has the pathologic features of spreading along the
portal vein. Through complete resection of the liver section or segment with its
portal pedicles, anatomic hepatectomy eliminates the potential intrahepatic metas-
tasis of HCC as much as possible. The overall survival of HCC could be improved
by anatomic hepatectomy (Hasegawa et al. 2005). It is well believed that the patients
with metastatic tumor, such as colorectal liver metastasis (CRLM), may benefit less
from anatomic hepatectomy than from HCC (Kokudo et al. 2001). However, there
are some exceptions. For those CRLM’s location is deep, LAH could prevent the
parenchymal division from the positive margin. The tumor boundary could turn out
to be fuzzy after the neoadjuvant chemotherapy. LAH could then become a more
reasonable and reliable choice to guarantee sufficient surgical margin than non-
anatomic hepatectomy.
LAH has the same inherited oncological value as the traditional open anatomic
hepatectomy. Meanwhile, LAH also involves almost all the necessary techniques
for laparoscopic non-anatomic hepatectomy, which in turn makes it become the
fundamental technique for all laparoscopic liver resection. The standards of these
basic techniques are relatively high and worthy of promoting.
1.3 Key Issues and Technique Details
1.3.1 Identification of Portal Pedicles and Root of Hepatic Vein
The main hepatic vessel control approaches, including the portal pedicles and root
of hepatic vein, have been shown in Fig. 1.3. The simultaneous control of portal
pedicles and hepatic vein, as the inflow and outflow vessels respectively, is the clas-
sic pattern of “bloodless” hepatectomy.
There are essentially three approaches for identification and transection of the
portal pedicles: hilar access approach, Glissonean pedicle approach, and fissural
approach (Yamamoto et al. 2014).
The hilar access approach means the dissection is in the sheath between the hep-
atoduodenal ligament and hilar plate. It is an extrahepatic approach without dissec-
tion of the liver parenchyma. With this approach, the secondary branches of the liver
artery, portal vein, and bile duct could be dissected and controlled separately. The
hepatic parenchyma could be often dissected and surgeon should try to control the
tertiary branches of the hilus vessels at the same time. The hilar access approach is
a delicate and demanding surgical procedure. Due to the common variations of
hepatic artery (Figs. 1.4 and 1.5) and bile duct, the dissection in the fascia could be
dangerous. The injuries to the hilus artery and portal vein might cause drastic
consequences.
The hilar access approach was used mainly in the early stage of LAH. It has been
considered to be time consuming and difficult to master. This technique may be
more suitable for radical lymphadenectomy of the liver hilus rather than the liver
resection itself.
The Glissonean pedicle approach can be achieved with or without parenchyma
dissection. The extrahepatic approach (usually for hemihepatectomy and sectionec-
tomy) is relatively easier than the intrahepatic approach (usually for segmentec-
tomy), and thereby determines that the segmentectomy is more challenging than the
major hepatectomy. Due to the essence of extra-fascial dissection, the Glissonean
pedicle approach is much safer than the hilar access approach for less incidence of
injury to the hilar vessels (Yamamoto et al. 2014).
The extrahepatic Glissonean pedicle approach is commonly used in the second-
ary branches near the hilus. The Glisson’s capsule between the hilar plate and liver
substance is incised, with the help of gentle opposite traction of the quadrant lobe
and hepatoduodenal ligament. The confluence of secondary portal pedicles was then
exposed and easy to manipulate. A common scenario is that the confluence of ante-
rior and posterior portal pedicle is revealed at same time. After transection of one of
the secondary portal pedicles, the relevant ischemic demarcation line becomes
observable.
The intrahepatic Glissonean pedicle approach is usually used in the segmentec-
tomy such as the segments 2, 4a, 5, 6, 7, and 8. When the portal pedicles of the
segment are hard to control out of the liver substance, the parenchyma is dissected
along an assumed boundary line to find the root of the portal pedicles. This line
could be roughly determined with the help of the hepatic surface landmark or
Vessels control in LAH
Portal pedicies Root of Hepatic Vein

1.3 Key Issues and Technique Details
Intra-fascial Extra-fascial Intrahepatic Extrahepatic

approach approach approach approach
Hilar access Glissonean pedicle Fissural

approach approach approach
Intrahepatic Extrahepatic
approach approach
Fig. 1.3 Classification of main vessel control approaches of LAH

7
a b c
d e
Fig. 1.4 Variations of extrahepatic arteries
a b
c d
Fig. 1.5 Variations of extrahepatic portal veins

1.3 Key Issues and Technique Details 9
Fig. 1.6 Fissural approach
intraoperative ultrasonography. So the primary cutting line need not be too long.
After transection of the pedicles, segmentectomy then could be finished along the
relatively more accurate ischemic line.
Compared with the hilar access approach, the Glissonean pedicle approach is
easier to handle and safer (Machado et al. 2011).
The fissural approach is mostly fit for the segmentectomy such as the segments 3
and 4b (Fig. 1.6). The umbilical fissure could be opened with or even without slight
liver substance dissection, and the pedicles of segments 3 and 4b are then con-
firmed. The fissural approach is special transformation of the Glissonean pedicle
approach.
There exists another way to handle the portal pedicles as in the laparoscopic left
lateral sectionectomy (Chang et al. 2007). This procedure needs neither hilar inci-
sion or liver parenchyma dissection nor the navigation of ultrasound or dyeing. It
simplifies dependence on the landmark of liver to achieve anatomic hepatectomy.
With the limited indications and simple operations, this method is easy to promote.
The details are shown in relevant chapter.
Identification of the root of hepatic vein could also be implemented in the
intrahepatic and extrahepatic approach (Figs. 1.7 and 1.8). The extra approach
is necessarily accompanied with a full liver mobilization. The intrahepatic
approach involves ligation of the root of hepatic vein during the parenchyma
dissection. The latter approach is believed to be faster and easier to operate
(Toro et al. 2015).
Fig. 1.7 Extrahepatic
a
Approach of identification
of the root of hepatic vein
(a) Left hepatic vein
(arrow) and (b) Right
hepatic vein (arrow)
Fig. 1.8 Intrahepatic
Approach of identification
of the root of hepatic vein
1.3.2 Prevention of Bleeding and Hemostasis
Bleeding is still the most important issue limiting the improvement of laparoscopic
liver resection (Shelat et al. 2015). The massive intraoperative blood loss along with
later blood transfusion would greatly damage the patients' immune system, affect
their postoperative recovery, and make tumors more likely to relapse. And it is also
the most common reason for the conversion to open surgery (Abu Hilal et al. 2010).
The prevention and control of bleeding during laparoscopic hepatectomy is achieved
by a number of integrated measures.
Measures to prevent bleeding is more important than those to stop bleeding
(Fig. 1.9). LAH itself is a fundamental method to prevent bleeding through ensuring
a “bloodless” cutting plane and controlling the inflow and outflow vessels as dis-
cussed above. Other favorable measures include carbon dioxide pneumoperito-
neum, low central venous pressure and airway pressure. Careful examination and
meticulous hemostasis should be consistently carried out throughout the whole
operation.
In face of bleeding, surgical members may have many options including bipolar
coagulation, vessel sealing devices, titanium clips, vascular locks, staplers, and
suture. The vessel-dependent indications should be clear for different measures
(Wakabayashi et al. 2015). Laparoscopic suture skill is the key to ensure the safety
of LAH. Without it, the complicated laparoscopic surgery would be a dangerous
speculation (Shelat et al. 2015).
When no progress is made in a certain period, conversion should be considered.
Conversion to open surgery should not be regarded as complication, but reasonable
surgical decision (Dagher et al. 2009).
Fig. 1.9 Ligation of left

inferior phrenic vein before
dissecting left hepatic vein
1.3.3 Parenchymal Dissection and Exposure of Hepatic Vein
The process of liver parenchymal dissection involves formation of the liver cutting
plane and exposure of the hepatic vein in LAH. The key is to find the right boundary
between the adjacent territories of the portal pedicels. The target specimen should
contain the tumor completely and the cancer-free liver parenchyma should be
reserved as much as possible.
Many energy devices and mechanical staples could be used in laparoscopic liver
parenchymal transection. The employed techniques are usually individualized
from different surgeons. Up until now, there is no clear evidence that a certain
device or technique is more advantageous (Dagher et al. 2009). It is vital that sur-
geons have a reliable insight into the merits and defects of devices and techniques
available to perform safe and efficient LAH. The flexible combination of various
methods and devices may be the best solution under the present conditions. The
basic liver surgery techniques are still the cornerstone of LAH, including delicate
dissection, enough exposure of the surgical field, and vascular suture skills
(Wakabayashi et al. 2015).
M. A. Machado divided the transection plane of pure laparoscopic right hemi-
hepatectomy into three continuous parts: anterior, middle, and posterior parts
(Machado et al. 2011) (Fig. 1.10).
The three parts involve different containing vessels inside and subsequent transec-
tion methods. There is no main vessel in the anterior part. It can be divided by ultra-
sonic scalpel along the ischemic line (Fig. 1.11). There exist hepatic short veins in the
posterior part. A staple should be used to transect this part as a whole (Fig. 1.12).
There are the right secondary main portal pedicles, the root of the RHV and the con-
siderable branches of the MHV in the middle part (Fig. 1.13). This part should be
transected with staples after the anterior and posterior parts. Such division and
sequence have brought LAH more safe and clear guidance (Machado et al. 2011).
Fig. 1.10 Three parts of

the transection plane of
laparoscopic right
hemihepatectomy
Fig. 1.11 Transection of

the anterior part

the posterior part

the middle part
The Couinaud segments are surrounded by the hepatic veins. The real anatomic
hepatectomy unavoidably involves exposure of the major hepatic veins on the cut-
ting plane. The complete exposure of intrahepatic hepatic veins is the essence of
hepatectomy. This also applies to LAH (Ishizawa et al. 2012).
Before start, all measures for prevention and control of bleeding should be
adopted as mentioned above in case of massive bleeding. The clamp crushing tech-
nique is still the basic skill to expose the hepatic veins as in open liver resection. The
tips of laparoscopic instruments are used to get rid of the hepatic substance adhering
to the venous wall by short reciprocated scrape (Ishizawa et al. 2012). The direction
of movement should be from the root to the peripheral, considering the inverted
tree-shape of hepatic vein (Honda et al. 2014).
1.3.4 Intraoperative Navigation
Intraoperative navigation provides functions of locating the liver tumor and its
relationship with intrahepatic vessel structures and guiding the consequent hepa-
tectomy. The ultrasonography is the most important means of intraoperative navi-
gation. The target portal pedicles could be found by intraoperative ultrasonography.
And then the ischemic or discoloration line could be demonstrated by transection
a b
Fig. 1.14 The routine examination order of laparoscopic intraoperative ultrasonography (a)
Longitudinal inspection; (b) Horizontal inspection
or dyeing. In recent researches, the fluorescein staining technique and augmented

reality technique have been used for the same purpose (Hallet et al. 2015).
The laparoscopic intraoperative ultrasonography is the key of LAH. Unlike the
flexibility in the open surgery, it is usually relatively fixed on the root of the detection
probe by trocar. A routine examination order is necessary to avoid any missed
diagnosis.
There are two basic inspection dimensionalities in laparoscopic intraoperative
ultrasonography: longitudinal and horizontal (Fig. 1.14). The longitudinal inspec-
tion is to move the ultrasound probe from the left to the right on the hepatic dia-
phragmatic surface. The long axis section of the left hepatic vein, middle hepatic
vein, retrohepatic inferior vena cava, and right hepatic vein will be shown on the
monitor in turn. The horizontal inspection is to move the ultrasound probe from the
top to the liver edge on the hepatic diaphragmatic surface. When the divisions of the
superior and inferior branches of the secondary portal vein are found, the borders
between 4a and 4b, 5 and 8, 6 and 7 are then identified. The position of the laparo-
scopic ultrasonography trocar should be carefully chosen in order to make the whole
liver available (Ishizawa et al. 2012).
Fluorescence imaging is also very useful in the intraoperative guidance of LLR,
which has been widely used since the late 2000s (Ishizawa et al. 2009). Based on the
dynamic ICG imaging, we developed a novel and feasible intraoperative guiding
method, which is named as tri-phase quadri-sectional imaging (TPQSI), which can
identify four anatomic sections during LLR (Fig. 1.15), including tumor, paraneo-
plastic area, ischemic area, and remnant area. Briefly, before surgery, ICG dye was
injected intravenously, and during the operation, tumor and paraneoplastic area on
the surface of liver would emit a pseudocolor-green light on the fusion images mode
Fig. 1.15 The four

anatomic sections
demonstrated using
tri-phase quadri-sectional
imaging. (a) tumor; (b)
paraneoplastic area; (c)
ischemic area; (d)
remnant area
Fig. 1.16 A 6-cm tumor and the paraneoplastic area in segment 5 and 8 were identified by fusion
IGFI
(Fig. 1.16) (sometimes there is not a clear line between these two areas). A signifi-
cant benefit is that IGFI could identify tiny subcapsular hepatic malignancies not
detected by visual inspection (Kudo et al. 2014) or conventional imaging modalities
(Terasawa et al. 2017), although deep-located tumors should be diagnosed by lapa-
roscopic intraoperative ultrasonography. After controlling the inflow of right liver,
ICG was intravenously injected, and the ischemic line on the liver surface would
appear, which divides the liver into two areas, the ischemic area and the remnant
area (Fig. 1.17). According to the staining boundaries, LAH could be performed
under a real-time navigation (Fig. 1.18).
Fig. 1.17 TPQSI after blood control: (a) tumor and paraneoplastic area; (b) unstaining section;
(c) remnant-staining section
Fig. 1.18 TPQSI after blood control: transection line based on the boundaries between section b
and c
With the help of laparoscopic intraoperative ultrasonography and TPQSI, the

accuracy of LAH is enhanced, and more tumor-free parenchyma is preserved while
the adequate surgical margin is also secured.
References
Abu Hilal M, et al. Bleeding and hemostasis in laparoscopic liver surgery. Surg Endosc.
2010;24(3):572–7.
Chang S, et al. Laparoscopy as a routine approach for left lateral sectionectomy. Br J Surg.
2007;94(1):58–63.
Dagher I, et al. Laparoscopic major hepatectomy: an evolution in standard of care. Ann Surg.
2009;250(5):856–60.
Hallet J, et al. Trans-thoracic minimally invasive liver resection guided by augmented reality. J Am
Coll Surg. 2015;220(5):e55–60.
Hasegawa K, et al. Prognostic impact of anatomic resection for hepatocellular carcinoma. Ann
Surg. 2005;242(2):252–9.
Honda G, et al. Totally laparoscopic anatomical hepatectomy exposing the major hepatic veins
from the root side: a case of the right anterior sectorectomy (with video). J Gastrointest Surg.
2014;18(7):1379–80.
Hu M, et al. Retroperitoneal laparoscopic hepatectomy: a novel approach. Surg Laparosc Endosc
Percutan Tech. 2011;21(5):e245–8.
Ishizawa T, et al. Real-time identification of liver cancers by using indocyanine green fluorescent
imaging. Cancer. 2009;115(11):2491–504.
Ishizawa T, et al. Laparoscopic segmentectomy of the liver: from segment I to VIII. Ann Surg.
2012;256(6):959–64.
Kokudo N, et al. Anatomical major resection versus nonanatomical limited resection for liver
metastases from colorectal carcinoma. Am J Surg. 2001;181(2):153–9.
Kudo H, et al. Visualization of subcapsular hepatic malignancy by indocyanine-green fluorescence
imaging during laparoscopic hepatectomy. Surg Endosc. 2014;28(8):2504–8.
Machado MA, Surjan RC, Makdissi FF. Video: intrahepatic Glissonian approach for pure laparo-
scopic right hemihepatectomy. Surg Endosc. 2011;25(12):3930–3.
Shelat VG, et al. Pure laparoscopic liver resection for large malignant tumors: does size matter?
Ann Surg Oncol. 2015;22(4):1288–93.
Terasawa M, et al. Applications of fusion-fluorescence imaging using indocyanine green in laparo-
scopic hepatectomy. Surg Endosc. 2017. https://doi.org/10.1007/s00464-017-5576-z.
Toro JP, et al. Detecting performance variance in complex surgical procedures: analysis of a step-
wise technique for laparoscopic right hepatectomy. Am J Surg. 2015;209(2):418–23.
Wakabayashi G, et al. Recommendations for laparoscopic liver resection: a report from the second
international consensus conference held in Morioka. Ann Surg. 2015;261(4):619–29.
Yamamoto M, et al. Tips for anatomical hepatectomy for hepatocellular carcinoma by the
Glissonean pedicle approach (with videos). J Hepatobiliary Pancreat Sci. 2014;21(8):E53–6.
Yoon YS, et al. Laparoscopic liver resection for centrally located tumors close to the hilum, major
hepatic veins, or inferior vena cava. Surgery. 2013;153(4):502–9.
Patient Positioning and Ports Placement
2
Abstract
Patient Positioning and Ports Placement are important to laparoscopic liver
resection. Ports placement for this procedure requires careful preoperative plan-
ning based on the anatomic location of the hepatic lesion. We suggest three dif-
ferent positions according to the lesion site.
Patient Positioning and Ports Placement are important to laparoscopic liver resec-
tion. Ports placement for this procedure requires careful preoperative planning
based on the anatomic location of the hepatic lesion. We suggest three different
positions according to the lesion site.
2.1 Patient Position
2.1.1 The First Position: Reverse Trendelenburg Position
The patient is placed in supine position with a 20-degree reverse-Trendelenburg

adjustment, which is suitable for the majority of laparoscopic liver surgery (Fig. 2.1).
Methods: The surgeon stands on the opposite side of the lesion (e.g., if lesion in
the left lateral lobe, the surgeon stands on the right side of the patient). The first
assistant stands on the other side of the patient. This position is appropriate for the
majority of laparoscopic liver surgery, such as local hepatectomy, left lateral lobec-
tomy, left hemihepatectomy, etc.
2.1.2 The Second Position: Lithotomy Position
Methods: The patient is placed in the supine position, with lower limbs apart
(Figs. 2.2 and 2.3), the surgeon stands between the legs with one assistant on each
side. We use this position in single-port laparoscopic surgery.

https://doi.org/10.1007/978-94-017-9735-1_2
20 2 Patient Positioning and Ports Placement
Monitor Surgeon Assistant
Anesthetist
Anesthesia machine
Assistant Instrument nurse
Monitor
Instrument table
Fig. 2.1 Operating room setup of reverse Trendelenburg position
Fig. 2.2 The side view of lithotomy position
2.1.3 The Third Position: Left Lateral Decubitus Position
The left lateral decubitus position with a steep reverse Trendelenburg position is
ideal for lesions in the right lobe—particularly those requiring mobilization of the
right lobe to gain access to the posterior surface (Fig. 2.4).
2.1 Patient Position 21
Fig. 2.3 The front view of lithotomy position
Fig. 2.4 The side view of left lateral decubitus position

2.2 Principle of Trocar Positioning
Positioning of port sites is different according to the tumor site. When the patient
is placed in position, pneumoperitoneum is achieved through a Veress needle under
the umbilicus to insufflate the peritoneal cavity to 14 mmHg. A first 10-mm trocar
is then placed under the umbilicus for laparoscope. The other two 12-mm trocars
are located in the upper abdomen, according to the location of the tumor. Besides
the two 12-mm trocars, a 5-mm trocar is then placed assisting in organ exposure,
traction, and suction.
2.2.1 Left Lateral Lobectomy and Left Hemihepatectomy
The surgeon stands on the right side of the patient, and the first main operating port
is located on the junction between the right midclavicular line and 4 cm below the
costal margin. The second main operating port position is located on the junction
between the left midclavicular line and a little bit below the costal margin. On the
left side of the anterior axillary line to establish assistant operation hole for 5 mm
trocar (Fig. 2.5).
12 mm 12 mm
5 mm
10 mm
Fig. 2.5 Port position for
left lateral lobectomy and
left hemihepatectomy
2.2 Principle of Trocar Positioning 23

right posterior lobectomy
12 mm
12 mm
5 mm 10 mm
2.2.2 Right Posterior Lobectomy
The surgeon stands on the left side of the patient, and the first main operating
port is located on the junction between the right midclavicular line and 4 cm
below the costal margin. The second main operating port position is located
below xiphoid bone. On the right anterior axillary line and 4 cm above the level
of umbilicus, a 5 mm trocar is then introduced to establish an assistant operating
port (Fig. 2.6).
2.2.3 Right Hemihepatectomy
The surgeon stands on the left side of the patient, and the first main operating port
is located on the junction between the right midclavicular line and 4 cm below the
costal margin. The second main operating port is located on the junction between
the left midclavicular line and a little bit below the costal margin. On the right ante-
rior axillary line and 4 cm above the level of umbilicus, a 5 mm trocar is introduced
to establish an assistant operating port (Fig. 2.7).

right hemihepatectomy
12 mm
12 mm
5 mm
10 mm
Preoperative Preparation
and Anesthesia for Laparoscopic 3
Liver Resection
Abstract
It is very important to do adequate preparation before surgery for laparoscopic liver
resection. Strict case selection and surgical instrument preparation play important
roles in the preparation. In this chapter, we focus on the preparation of patients and
surgical instruments, and give a brief introduction to the selection of anesthesia.
It is very important to do adequate preparation before surgery for laparoscopic liver

resection. Strict case selection and surgical instrument preparation play important
roles in the preparation. In this chapter, we focus on the preparation of patients and
surgical instruments, and give a brief introduction to the selection of anesthesia.
3.1 Preoperative Evaluation of Patients
After admission, the patient who will receive laparoscopic liver resection should be eval-
uated for general state and nutritional status, and measures should be taken to correct the
anemia, low serum albumin, and water electrolyte imbalance and to improve the nutri-
tional status and liver function. Also, according to the imaging examination, the location,
size, nature, etc. of the liver lesion should be seriously assessed to confirm indications for
surgery. At the same time, a comprehensive assessment of heart, liver, lung, and other
organs function will contribute to recognize contraindications of surgery.
3.1.1 Imaging Examination
3.1.1.1 Ultrasonography
Ultrasonography is a procedure used for liver tumor screening. The results of ultrasound
examination are subjective and relevant to the expertise of the operator and technical
limitations, thus ultrasonography can’t be used to determine the surgical approaches.

https://doi.org/10.1007/978-94-017-9735-1_3
26 3 Preoperative Preparation and Anesthesia for Laparoscopic Liver Resection
Intraoperative ultrasound is necessary to laparoscopic liver surgery, especially in the

local resection of liver tumors.
3.1.1.2 CT
CT can clearly show the density difference between liver lesions and the liver
parenchyma. It also shows the blood supply of lesions and its internal structure.
Cross-section reconstruction and three-dimensional reconstruction can be achieved
by CT scan. Preoperative CT examination of liver disease is more accurate than
ultrasonography.
3.1.1.3 MRI
The resolution of MRI is higher than CT, and there are a variety of imaging
sequences. Besides, MRI has no radioactive damage and its contrast agent has less
side effects. For liver cancer, especially small hepatocellular carcinoma (less than
2 cm), detection ability of MRI is better than that of CT. MRI is recommended as a
routine use for liver tumor diagnosis.
3.1.1.4 PET-CT
PET-CT has obvious advantages in the identification of the nature of the tumor with
the fluorine-18-FDG accumulating in the tissues of malignant tumor cells. PET-CT
has an obvious advantage in the detection of extrahepatic lesions, which is benefi-
cial for comprehensive preoperative staging of patients with malignant liver tumors.
Due to the high cost, PET-CT is not used as the routine examination.
3.1.2 Systemic Organ Function Evaluation
3.1.2.1 Cardiac Function

Before laparoscopic liver resection, combine the patient’s history and examination
results (electrocardiogram and Doppler echocardiography, 24 h dynamic electrocar-
diogram, coronary angiography) to clarify whether there is surgical contraindication.
3.1.2.2 Respiratory Function

Pleural effusion, atelectasis, and pulmonary infection are common complications
after liver resection. Due to a long time of pneumoperitoneum during surgery, lapa-
roscopic surgery has more significant side effect on respiratory and circulation com-
pared with open surgery, so the risk of respiratory system complication will be
significantly increased in the patients with respiratory disease. According to the
patients’ blood gas analysis, pulmonary function examination results, objective eval-
uation of the respiratory system will be achieved. Respiratory function is also very
difficult to greatly improve in a short period of time, therefore patients with respira-
tory system diseases should be carefully choose to undergo laparoscopic surgery.
3.1 Preoperative Evaluation of Patients 27
3.1.2.3 Renal Function

Patients with liver cancer, especially hepatocellular carcinoma usually accompa-
nied with chronic viral hepatitis and chronic liver damage, are prone to suffer
postoperative ascites and even hepatorenal syndrome, etc. For patients with mild
renal dysfunction, the electrolyte and acid–base balance disorder, low protein,
etc. should be corrected appropriately before the operation. Meanwhile, for
patients with liver cirrhosis, the perioperative infusion should be moderate, and
it’s beneficial to encourage patients to eat, so as to avoid fluid retention and renal
insufficiency.
3.1.2.4 Liver Function

Under normal circumstances, the remnant liver after resection of 70–75% liver
tissue could still maintain the normal physiological function of the liver. However,
most of our patients with hepatocellular carcinoma (HCC) have chronic viral hep-
atitis, and in such patients, liver function is damaged to various degrees. After
hepatic resection these patients are prone to postoperative liver function incom-
plete and even liver failure. Therefore, it is very important to assess the prognosis
of patients with liver function and liver reserve function before liver resection.
There are many methods to evaluate liver function, but there is no single method
that can accurately and comprehensively reflect the severity of liver disease. The
most basic method of preoperative liver function evaluation is the Child Turcotte
Pugh (CTP) score of liver function which mainly includes five indicators (albu-
min, ascites, hepatic encephalopathy, bilirubin, and prothrombin time). According
to the severity of the disease, each of the 5 indexes is counted as 1, 2, or 3, and the
total score of 5 indexes can be divided into three grades: 5–6 points for Grade A,
7–9 points for grade B, and l0–15 points for C-class. It is generally believed that
the patients with grade C in CTP score can hardly tolerate liver resection, and the
mortality rate after liver resection of patients with grade B is significantly higher
than that of the patients with Grade A. CTP score has the advantages of simple,
practical, and economical. But the shortcomings of CTP score are also very obvi-
ous, for instance, no proper weight are taken into account among all these indica-
tors, so it is hard to grade the ascites and hepatic encephalopathy. Indocyanine
green clearance (IGG) is a synthetic, non-toxic, photosensitive dye in deep blue
color. Due to its metabolic characteristics, the ICG excretion test is considered to
be sensitive to the liver reserve function and is widely used in the field of liver
resection. Combined application of CTP classification and the ICG excretive test
may achieve a comprehensive and accurate assessment of liver function.
3.1.2.5 Patients with Psychological Expectations

All patients undergoing laparoscopic liver resection need to be prepared for conver-
sion to open surgery. The possibility and necessity of conversion should be explained
to patients and their families before operation.
28 3 Preoperative Preparation and Anesthesia for Laparoscopic Liver Resection
3.2 Anesthesia in Laparoscopic Liver Resection
1. Before surgery, anesthesiologist should understand patient’s medical history,

evaluate patient’s general state and the functions of important organs, so as to
make sure there is no anesthetic contraindications. The anesthesiologist should
also communicate with the surgeon to know operative strategy and what emer-
gency may happen during the surgery.
2. Choice of anesthesia: Laparoscopic liver resection is generally adopted by gen-
eral anesthesia under endotracheal intubation. Laparoscopic and endoscopic
surgery experts suggested general anesthesia combined with epidural anesthesia
in laparoscopic liver surgery, because epidural anesthesia can block afferent
stimulation of injury during the operation and reduce the degree of stress
response. For patients who have general anesthesia combined with epidural
anesthesia and may get stable respiration and circulation during surgery, their
postoperative recovery time and recovery quality is superior to that of patients
with only general anesthesia. But if the patient is accompanied with cirrhosis and
coagulation dysfunction, epidural puncture is likely to cause epidural hematoma.
Anesthesia doctors should carefully select anesthesia method according to the
specific circumstances of patients. General anesthesia can be induced by the
standard drug, but after liver resection, the residual liver’s ability to clear the
anesthesia drug will be inhibited, so anesthesiologist should pay attention to the
interaction between anesthetics and liver.
3. It’s routine monitoring vital signs such as ECG, SpO2, and other indexes
including urine volume, body temperature, blood glucose, electrolyte, blood
coagulation function, and blood gas analysis. If the monitoring process is
relatively complex, it is best to use invasive approach. For laparoscopic liver
resection surgery, anesthesiologist not only deal with intraoperative bleeding
problems during open hepatectomy, but also need to pay attention to persis-
tent CO2 pneumoperitoneum. To reduce the side effect of pneumoperitoneum
on the body is crucial for anesthesiologist during the operation. In pneumo-
peritoneum state, the pathophysiological changes including large amount of
CO2 absorbed by peritoneal, an increase in intra-abdominal pressure, diaphrag-
matic elevation, increased airway pressure, and reduced lung capacity, could
lead to pulmonary ventilation perfusion imbalance, hypercapnia, and acidosis.
Therefore, monitoring of PaCO2 is significant.
Laparoscopic Liver Cysts Fenestration
4
Abstract
Surgical treatments for liver cysts include: fenestration, liver resection with
fenestration, regular hepatectomy, liver transplantation, and so on. Comparing
with laparotomy, laparoscopic surgery has some advantages, including minimal
invasiveness, short surgery time, quick recovery, simple operation, which may be
the reason why laparoscopic fenestration has become the most popular method
for liver cysts treatment. However, attention should be paid that for hepatic cyst-
adenoma, hepatic cystadenocarcinoma, and hepatic cystic echinococcosis, open
hepatectomy is still the optimal treatment.
Surgical treatments for liver cysts include: fenestration, liver resection with fenes-
tration, regular hepatectomy, liver transplantation, and so on. Comparing with
laparotomy, laparoscopic surgery has some advantages, including minimal inva-
siveness, short surgery time, quick recovery, simple operation, which may be the
reason why laparoscopic fenestration has become the most popular method for
liver cysts treatment. However, attention should be paid that for hepatic cystadenoma,
hepatic cystadenocarcinoma, and hepatic cystic echinococcosis, open hepatectomy
is still the optimal treatment.
4.1 Indications and Contraindications
4.1.1 Indications
1 . Symptomatic liver cyst (non-parasitic and non-malignant)

2. Located on the surface of the liver
3. No communication with bile ducts
4. Single or multiple liver cysts
5. Sudden enlargement in cyst’s volume (>10 cm)

https://doi.org/10.1007/978-94-017-9735-1_4
30 4 Laparoscopic Liver Cysts Fenestration
4.1.2 Contraindication
1 . Communication with bile ducts

2. Liver cystadenoma or cystadenocarcinoma
3. Parasitic liver cysts
4. Bacterial liver abscess
5. Suspected malignant tumors
4.2 Procedure
1. Position and trocars’ locations: The patient is placed in supine position with
surgeons between the patient’s legs. A 10 mm trocar is placed via an infra-
umbilical incision. Then a pressure-controlled CO2 pneumoperitoneum is main-
tained at 12–14 mmHg, with end-tidal CO2 concentration monitored continuously.
Through this port, a 30° laparoscope is introduced to detect abdominal viscera
overall and make sure the lesion’s location. Then, according to its location, two
additional trocars are inserted at suitable sites. When the surgeon puncturing
abdominal wall, ensure trocar’s sharp point under your sight in case of abdominal
or retroperitoneal organs injury.
2. Laparoscopy and intervention: A laparoscope is introduced to have a further
determination of lesions’ site, number, interface relations between liver and
cysts. When the lesion is confirmed as simple liver cyst, we usually use a
monopolar electrocoagulation or ultrasonic dissector to incise a 5 mm hole on
the cyst wall. Then a sucker is punctured to aspirate intra-cystic fluid out
(Fig. 4.1). When necessary, it is recommended to have a laparoscopic fluid col-
lection with needle to determine fluid quality (bile, mucus) firstly. If the lesion
is suspected as a non-simple cyst preoperatively, the intra-cystic fluid should
be examined pathologically, bacteriologically, biochemically.
3. Cysts fenestration: Deroofing is performed by monopolar electrocoagulation
forceps or ultrasonic dissector or by Ligasure (Fig. 4.2). A sucker is positioned
to aspirate the residual liquid. After above procedures, a cautious observation of
Fig. 4.1 Incise the cyst

using ultrasounic scalpel
and aspirate intra-cystic
fluid out
4.2 Procedure 31
the cyst wall is needed. If there are relatively thick vessels on the wall, it’s
recommended to occlude proximal bile ducts of these vessels so as to avoid bile
leak (Fig. 4.3). The purpose of the surgery is sufficient fenestration, so that liver
resection along the lesion’s line is not essential (Fig. 4.4). For polycystic liver
Fig. 4.2 Deroof the cyst

and resect the cystic wall
Fig. 4.3 Resect the

whole cystic wall
Fig. 4.4 After the

deroofing, the cystic
cavity shows multiple
fibrous septa
32 4 Laparoscopic Liver Cysts Fenestration
Fig. 4.5 Clamp the vessels

in the cystic cavity
diseases, the management should be taken from outer lesions to inner ones. In
essence, it is unnecessary to deal with the residual cystic cavity. But in consider-
ation of postoperative adhesion which may lead to the atresia of fenestration,
especially in polycystic liver disease and cysts near the diaphragm, the secretory
epithelium within the residual cavity should be destroyed by ethanol or argon
knife.
4 . Drainage: When all the cysts have been deroofed and no hemorrhage and bile
leak maintained. A draining tube is placed in the cysts cavity. Additional tubes
are feasible, if needed. Then insufflation was stopped and trocars are withdrawn.
All of the trocar insertion sites should be carefully closed.
4.3 Key Techniques
1. Management of hemorrhage in the cutting edge of cystic wall: Because con-

comitant bile ducts may exist in most circumstances, the bleeding sites should be
clamped by absorbable clip (Fig. 4.5).
2. Management of residual cystic wall: Notice the orientation of hepatic vein and
bile duct during the argon plasma coagulation, and the coagulator should be
perpendicular to the cystic wall.
4.4 Complications
Although complications of this surgery are rare, there are still reports about hemor-
rhage and bile leak. With regard to bleeding from the artery, selective arterial embo-
lization or laparoscopic hemostasis should be taken without delay. For bile leak,
thorough drainage is needed and percutaneous abdominal puncture drainage by
ultrasonic or CT guidance should be conducted if necessary.
4.5 Notes 33
4.5 Notes
1 . Close observation of patients’ examinations and tests

2. Pay attention to variability of drainage’s volume and characteristic
3. Patients could have food and drink, activities on the second day after the
operation
4. Drainage can be removed, usually 48–72 h postoperatively, if no bleeding and
bile leak.
5. Before discharge, an abdominal CT is needed to analyze the residual cystic cavity’s
status.
Laparoscopic Partial Hepatectomy
5
Abstract
Laparoscopic partial resection or irregular resection of liver tumors are the most
undefined type of laparoscopic hepatectomy. Resection of some marginal tumors
without major ducts vessels is relatively easy. However, for tumors near the first
and second porta hepatis or in segments 7, 8, partial resection is relatively diffi-
cult. The overall principle is to keep a distance of at least 1 cm from the edge
of the tumor, remove the tumor integrallty, ensure a clean edge, and reduce
unnecessary tissue damage.
5.1.1 Indications
1. Tumors in segment II, III, IVa, V, VI in Couinaud’s segment are best candidates
for laparoscopic partial hepatectomy.
2. The size and location of the tumor should not influence the dissection of the first
and second porta hepatis. The diameter of tumor should be less than 15 cm in
benign cases and 10 cm in malignant cases. Tumor with excessive size limits the
operative space and influences the exposure of lesion, in addition, it leaves large
cut surface apt to errhysis.
3. The Child-Pugh classification should be at least Grade B, and there should not be
any severe structural disease in other organs. The volume of residual liver has to
be able to fulfill the physical demand.
4. Patients without complicated upper abdominal operation history, ascites, jaun-
dice, severe cirrhosis, and portal hypertension.
5. Tumor located in liver with intact capsule and without metastasis.
35
© Springer Science+Business Media B.V. 2017
https://doi.org/10.1007/978-94-017-9735-1_5
36 5 Laparoscopic Partial Hepatectomy
5.1.2 Contraindications
1. Tumor violating inferior vena cava or the root of hepatic vein, which makes the
exposure and hemostasis difficult under laparoscopy, is the contradiction of lapa-
roscopic partial hepatectomy.
2. Liver cancer accompanied by intrahepatic metastasis, portal vein tumor throm-
bus, hilar lymph node metastasis, or unclear tumor boundary is also the
contraindication.
3. Patients with complicated upper abdominal operation history and severe intra-
abdominal adhesion, ascites, jaundice, severe cirrhosis, and portal hypertension
are relative contraindication.
4. Patients with Grade C in Child-Pugh classification or severe dysfunction in other
vital organs.
5. Tumor with excessive size interferes the exposure and dissection of first or sec-
ond porta hepatis.
6. Patients with severe cirrhosis, ascites, jaundice, or hemorrhagic tendency.
7. Patients with poor general condition and unable to withstand major operation
and anesthesia.
5.2 Procedure
5.2.1 Patient’s Position and Trocar Placement
Patient’s position are decided based on the location of the tumor. Typically, the
patient is on the supine position. According to the location of the tumor and the
habit of surgeons, the 4-trocar technique is usually performed in this procedure. For
detailed information, please see Chap. 2.
5.2.2 Laparoscopic Exploration
In combination with imaging examination (Fig. 5.1), laparoscopy is performed

to explore the status of liver and other organs, and when the tumor is recog-
nized, its related situation should be assured, such as the location, size, number
of tumor, metastasis on the liver surface, enlargement of hilar lymph nodes,
adhesion of tumor with surrounding organs, and the degree of cirrhosis (Figs. 5.2
and 5.3). If necessary, especially when the tumor locates deep inside the paren-
chyma and unable to be seen from the liver surface, intraoperative laparoscopic
ultrasonography should be used to detect the location, size, and extent of the
hepatic tumor, its relationship to the hepatic vasculature, and to assist the
estimation of operation feasibility and selection of proper operation plan with
adequate margins.
Wedge resection is suitable for local liver tumor or tumor in the peripheral of
liver and sometimes the resection can be extended.
5.2 Procedure 37
Fig. 5.1 MRI shows the

tumor above the
gallbladder bed in the right
liver
Fig. 5.2 Laparoscopic
exploration, the tumor is
located in segment 5 and
near the gallbladder bed
exploration, the tumor is
located in the hepatic
diaphragmatic surface
5.2.3 Partial Hepatectomy
For partial resection of small tumors located in the peripheral of right or left liver,
technical requirements is undemanding, which doesn’t need dissection of the first
and second porta hepatis. Based on the different location of tumors, related liga-
ments transected and part of the liver is dissociated, and a transection plane is out-
lined on the liver capsule 1–2 cm away from the tumor by electrocoagulator
(Fig. 5.4). Then liver parenchyma under the line of transection is dissected by ultra-
sonic scalpel, during which small hemorrhage can be controlled by mono-polar or
bipolar electrocoagulation, while large vessels and bile ducts must be clipped by
Hem-o-lock (Figs. 5.5 and 5.6). Attention should be paid to timely flush operative
field and aspirate fluid, so as to make the visual filed clean and clear (Fig. 5.7).
Fig. 5.4 Outline the

transection plane on the
liver capsule
Fig. 5.5 Dissect the liver

parenchyma along the
pre-set transection plane
5.2 Procedure 39
Fig. 5.6 Control the active

bleeding using BiClamp
forceps
Fig. 5.7 Clamp the inflow

vessels using absorbable
clip
If tumors located in thin part of liver such as left lateral lobe, wedge transection of
liver parenchyma can be carried out by endoscopic linear cutter staplers in a V-shape.
For large-scale partial hepatectomy, the incisional surface is large and the vessels
can’t be ligated like independent pedicle ligation in anatomic hepatectomy. For the
purpose of reducing hemorrhage, familiarity with pre-operative imaging data, espe-
cially the enhanced CT or MRI, and performing 3-D reconstruction of the lesion is
crucial and may help to decide the main blood supply of tumor. With the help of 3-D
reconstruction of tumor supply vessels or guidance by intra-operative ultrasonogra-
phy when necessary, surgeons dissect liver parenchyma, find and ligate or clip the
main supply vessels, and then resect the residual parenchyma. Under the circum-
stance of massive hemorrhage and unclear vision, it’s suggested to press the bleed-
ing point with gauze, resect the tumor fast, and then suture the bleeding vessels.
Fig. 5.8 Hemostasis in the

cutting edge using argon
plasma coagulator
5.2.4 Hemostasis and Drainage
After resection of the lesion, thorough hemostasis of the incisional surface should
be achieved by argon beam coagulator or electrocautery (bio electrocoagulator or
Biclamp may achieve better hemostasis) (Fig. 5.8), and then biomedical fibrin glue
or absorbable hemostatic gauze should be covered on the incisional surface. Whether
placing the drainage tube depends on the size of incisional surface and the state of
hemostasis. In general, at the last of operation, a fine latex tube is placed through the
right trocar and then removed on the first postoperative day if no hemorrhage and
biliary fistula occurs. Liver specimen is placed in a plastic bag and extracted from
the abdominal cavity through a 3–5 cm enlarged trocar incision (usually under the
umbilicus). The liver specimen can also be extracted from posterior fornix in mar-
ried female patients.
5.3 Major Operating Points
1. Patient position and ports placement is crucial. D uring the process of ports place-
ment, the feasibility and convenience of the transection line of liver, the dissocia-
tion of liver, utilization of endoscopic cutter stapler, extraction of specimen and
conversion to laparotomy should also be taken into account.
2. We recommend using the ultrasonic scalpel combined with Biclamp for liver
transection and using bipolar and ligasure for electrocoagulation.
3. Make sure a negative margin in malignant tumors.
4. Make a reasonable plan for the transection line of liver.
5. The order of liver transection and hemostasis of incisional surface vary from dif-
ferent types of hemorrhage. Some types of hemorrhage should be stopped imme-
diately while other types be stopped after the resection of lesion.
5.4 Complications 41
6. In order to maintain safety, the laparoscopic partial hepatectomy should be con-

versed to laparotomy timely under certain circumstances: (1) Extensive intra-
abdominal adhesions causing difficulty in dissection, severe hemorrhage or
rupture of digestive tract. (2) Tumor with large size unable to dissociation, influ-
encing the dissection and exposure of the first and second porta hepatis. (3)
Massive hemorrhage unable to be stopped efficiently, especially in cirrhosis
patients. Intra-operative bleeding is a critical factor to the prognosis of patients,
thus, it’s suggested to convert to laparotomy under strict criterion and try not to
perform blood transfusion. For benign tumor with relative normal liver function,
such as hemangioma, operation can be continued with autologous transfusion.
However, blood loss at 800 ml is the alert for conversion, and conversion should
be carried out immediately if the operation can’t be finished when blood loss at
1200 ml. (4) In case of the injury of extra-hepatic vein trunk unable to be repaired
fast (such as clipping the crevasse at once), to avoid CO2 embolism, surgeons
should exhaust intra-abdominal gases and conversion to laparotomy as soon as
possible. Be careful to avoid clipping or suturing the crevasse repeatedly, which
may enlarge the crevasse and cause serious consequences. (5) Sudden hemor-
rhage which is unable to be expeditiously controlled, such as bleeding of intra-
hepatic vein or tumor rupture, should be pressed to control temporarily, and then
the surgery should be converted to laparotomy for further operation. (6) During
the operation, when the following situations are confirmed, such as liver cancer
accompanied by intrahepatic metastasis, portal vein tumor thrombus, hilar lymph
node metastasis or unclear tumor territory which may influence the radical prin-
ciples of malignancy resection, the laparoscopy should be converted to
laparotomy.
5.4 Complications
5.4.1 Intra-Operative Hemorrhage
Laparoscopic surgery, in the strict sense, should be a “bloodless” surgery and

achieve “hemostasis priority to incision.” Once bleeding occurs in laparoscopic sur-
gery, surgeons will lose clear vision immediately, and it’s unlikely to clear the blood
away and press the bleeding site fast just like in the laparotomy. Therefore, hemor-
rhage is the most common complication of laparoscopic surgery and the main rea-
son of conversion. Strategies should be taken to prevent hemorrhage in laparoscopic
liver resection. For example, surgeons should carefully study the preoperative imag-
ing data, determine the lesion site and the territory of liver resection, so as to make
a scientific operation plan. Surgeons should also be careful during operation and
avoid damaging large blood vessels. More than that, particular attention should be
paid when dissecting the second porta hepatis, and it’s advocated to transect hepatic
veins inside the liver parenchyma instead of out of the parenchyma.
If an unexpected bleeding occurred during the operation, surgeons must remain
calm. The assistant who holds laparoscope should try to maintain the view and keep
distant from the bleeding site to avoid the lens shielding by blood. The operator uses
the laparoscopic instruments to press the hemorrhage site temporarily to reduce
bleeding, during which the assistant aspirates the blood quickly to find out the spe-
cific blood site and its origin, and then decides the further appropriate hemostatic
method.
1. Hemorrhage from the first porta hepatis: Hemorrhage from branches of the por-
tal vein or hepatic artery, whose color is more vivid, is in a “spewing” or “Jet”
shape. As long as operator controls bleeding with left hand and the assistant
aspirates the blood, the operator can clip or suture the bleeding site under direct
vision with right hand. Sometimes when dissecting one side of the portal vein,
small branches of caudate lobe on the posterior wall of portal vein will be tore,
which is usually more difficult to deal with. One effective way to dispose that is
to keep dissecting the branches of portal vein and then clip or suture the branches.
The another method is to insert an absorbable hemostatic gauze or sponge into
the posterior of portal vein, press the bleeding site for a few minutes and then
continue the operation after the bleeding is controlled. Never blindly clip or elec-
trocoagulate repeatedly in the blood, otherwise there is the risk of injury in the
contralateral bile duct.
2. Hemorrhage during liver resection: If the color of blood is vivid, the blood
may come from the “infusion vessels,” and it can be stopped by bio-polar
electrocoagulator. However, when the color of blood is dark and the pressure
is low, the blood may come from branches of hepatic veins. In this situation,
as the wall of hepatic veins is thin and prone to be tore, absorbable clips
should be used to clip both the hepatic vein and its surrounding parenchyma
under the bleeding site, instead of lifting up the vessels and then clipping
them like in the case of processing portal vein and hepatic artery hemorrhage.
In order to prevent gas e mbolism, the open hepatic vein shouldn’t be clipped
repeatedly when it’s still bleeding. If the bleeding can’t be controlled after
clipping one to two times, it’s suggested to use the gauze to press the bleeding
site for a few minutes. For the pressure of hepatic vein is low, the bleeding
may ameliorate or stop, and then choose to suture or press the bleeding site
based on the actual situation.
3. Hemorrhage from the second porta hepatis: In general, hemorrhage from the
second porta hepatis is from the injured hepatic veins or inferior vena cava. If the
crevasse is small, the operation can continue after clamping the crevasse with
absorbable clip. However, if the crevasse is large, the hemorrhage should be
controlled by titanium clip or gauze, and then immediately covert to laparotomy
to repair the vessel damage. It’s recommended not to suture the hepatic vein
under the pneumoperitoneum in laparoscopy, as it may enlarge the crevasse or
cause gas embolism.
5.5 Notes 43
5.4.2 CO2 Embolism
Generally,CO2 embolism occurs when hepatic vein is injured and high pressure CO2
gets into the heart through venous system, which is one of the most common causes
of death in laparoscopic liver resection. Even though many studies have been done
on the prevention of CO2 embolism, there are few effective ways to solve this prob-
lem. To prevent CO2 embolism, it’s suggested to dissect the hepatic vein outside of
the liver before parenchyma transection and clip the vein with titanium clip. Left
and right hepatic vein can both be dissected for 1–2 cm outside of the liver in lapa-
roscopy. But it should be noted that transecting the hepatic vein outside of the liver
parenchyma is very dangerous. If disposing inappropriately, it may lead to the death
of patient in a short time. In laparoscopic left lateral lobectomy, there’s no need to
dissect left hepatic vein outside of the liver parenchyma.
5.4.3 Biliary Fistula
In the process of parenchyma transection, sometimes it may occur to bile leak. After
clearing the intra-abdominal operative area, use a dry gauze to wipe the incisional
surface so as to check whether bile leak exists. If the leak comes from the cut end of
bile duct, it needs to be clipped or sutured. However, when the bile leak is from the
crevasse of bile duct in the residual liver, the crevasse needs to be repaired by fine
needle. Referring to the post-operative biliary fistula, when the volume of bile leak
is limited, the fistula can be healed by keeping the drainage tube fluent. However,
when the volume of bile leak is large or the bile diffuses among the abdominal cav-
ity, laparoscopic or open exploration should be carried out to ascertain the status of
biliary fistula and then dispose the fistula.
5.5 Notes
1 . Closely observe vital signs of patients after the surgery.

2. Pay attention to the volume and property of drainage fluid.
3. Sustain the balance of water, electrolyte, and acid–base metabolism.
4. Remove the nasogastric decompression tube 6 h after the surgery, give the
patients fluid diet and then normal diet gradually.
Laparoscopic Single-Site Hepatectomy
6
Abstract
With the improvement of laparoscopic instruments and surgical experience,
significant development has been gained in laparoscopic liver surgery. However,
it is still the dream of both surgeons and patients to reduce the surgical injury to
the maximum extent. In recent years, laparoscopic single-site surgery has been
constantly tried as a new challenging technique. Laparoscopic single-site hepa-
tectomy may play a promising role in the field of the minimally invasive surgery.
With the improvement of laparoscopic instruments and surgical experience, signifi-

cant development has been gained in laparoscopic liver surgery. However, it is still
the dream of both surgeons and patients to reduce the surgical injury to the maxi-
mum extent. In recent years, laparoscopic single-site surgery has been constantly
tried as a new challenging technique. Laparoscopic single-site hepatectomy may
play a promising role in the field of the minimally invasive surgery.
6.1 Indications
1 . Malignant tumor, diameter ≤2.5 cm; or benign tumor, diameter ≤5 cm.

2. Lesions located in the segments 3 & 4b, protruding from the surface of the liver.
3. No morbid obesity; No history of upper abdominal surgery (Fig. 6.1).
6.2 Steps and Key Techniques
1. Patient is in the reverse Trendelenburg position with two legs apart, general intra-
venous anesthesia, mechanical ventilation with laryngeal mask or endotracheal
intubation. The surgeon stands on the middle, and the assistants on the sides of
the surgeon (Figs. 6.2 and 6.3).

https://doi.org/10.1007/978-94-017-9735-1_6
46 6 Laparoscopic Single-Site Hepatectomy
Fig. 6.1 Focal nodular

hyperplasia (FNH) located
in Segment 3
Fig. 6.2 Position of the patient
Fig. 6.3 Position of surgeons

6.2 Steps and Key Techniques 47
Fig. 6.4 The Triport access
Fig. 6.5 The three 5 mm trocars’ access
2. The Triport is, or three adjacent 5 mm transumbilical trocars are used to build the
access through the abdominal wall; the 30° bendable 5 mm laparoscope; other
laparoscopic instruments include dissecting forceps, grasping forceps and
scissors, endoscopic linear staples, harmonic scalpel, Biclamp and LigaSure
(Figs. 6.4 and 6.5).
3. The long-distance laparoscopic observation at most time. When a magnifying
vision is needed, the laparoscope is adjusted firstly and then the other surgical
instruments; endoscopic linear staples with joint are more preferable.
4. Other than harmonic scalpel resection alone, the wedge resection can also be
performed by two crossed endoscopic linear staples (Figs. 6.6 and 6.7).
5. Postoperative drainage (Fig. 6.8)
48 6 Laparoscopic Single-Site Hepatectomy
Fig. 6.6 Hepatectomy by

harmonic scalpel
Fig. 6.7 Hepatectomy by

endoscopic linear staples
Fig. 6.8 Transumbilical
postoperative drainage
6.5 Notes 49
a b
Fig. 6.9 The comparison of incisions of the laparoscopic single-site hepatectomy: (a) 1 day after
surgery; (b) 4 weeks after surgery
6.3 Advantages
Laparoscopic single-site hepatectomy can reduce the injury of the abdominal wall
and subsequent postoperative pain. Its obvious scarless characteristic can meet the
cosmetic needs of patients (Fig. 6.9).
6.4 Disadvantages
1. Laparoscopic instruments remain to be improved: There are no specialized lapa-

roscopic single-site dissecting forceps or linear staples. The single-site laparo-
scopic instrument should be able to rotate by multiangles with a sufficient length
to avoid the mutual interference. To use the conventional instruments for laparo-
scopic single-site surgery is difficult to cope with the complex surgeries or dif-
ficult situation such as massive bleeding.
2. Laparoscopic lens remains to be improved: The 5 mm lens gets less light through
and results in an unclear gloomy surgical field.
3. To remove the specimen, the abdominal incision often need be expanded. The
oversized incision may make single-site surgery meaningless. In this case, the
new approach, such as vaginal formix, may be considered.
6.5 Notes
1 . Extra conscious should be paid to prevent the blockage of the drainage tube.
2. Cases should be performed with a strict inclusion criteria, and conversion to
mutiple-trocar method or even open procedure should be concerned if necessary.
Laparoscopic Left Lateral Sectionectomy
7
Abstract
Left lateral section contains the segments 2 and 3. The unique anatomical struc-
ture of the left lateral section makes laparoscopic left lateral sectionectomy
(LLLS) one of the most applied laparoscopic liver resection surgeries. With
almost the same or even shorted operation time, LLLS has the advantages such
as smaller incision and less injuries. The short-term prognosis of LLLS is signifi-
cantly better than that of open surgery. According to our own experience, we
brought up a practical method called “Seven-step liver transection.”
Left lateral section contains the segments 2 and 3. The unique anatomical structure
of the left lateral section makes laparoscopic left lateral sectionectomy (LLLS) one
of the most applied laparoscopic liver resection surgeries. With almost the same or
even shorted operation time, LLLS has the advantages such as smaller incision and
less injuries. The short-term prognosis of LLLS is significantly better than that of
open surgery. According to our own experience, we brought up a practical method
called “Seven-step liver transection.”
7.1.1 Indications
1. Benign or malignant tumor located limitedly in the left lateral section; No limit
for the size of the tumor only if porta hepatis available.
2. Intrahepatic bile duct stones with a left atrophy lateral section.
3. Liver function of Child B or better
4. No history of complex abdominal surgery

https://doi.org/10.1007/978-94-017-9735-1_7
52 7 Laparoscopic Left Lateral Sectionectomy
1. General contraindications, such as metastatic lesions or adjacent organ

infiltration;
2. Lymphadenectomy is needed for the metastatic lymphatic lesions. Embolectomy is
needed for the cancer thrombus in the bile duct, portal vein or inferior vena cava;
3. Compression or infiltration to the first or second porta hepatis;
4. History of complex abdominal surgery;
5. The general condition is too poor to tolerate pneumoperitoneum or general anesthesia.
7.2 Steps
7.2.1 Patient Position and Trocar Distribution
The supine position and intubated intravenous anesthesia are adopted. The four-
trocar method is taken. The main and auxiliary 12 mm operation trocars are placed
on the subcostal left and right side of the rectus abdominis respectively. The assis-
tant 5 mm trocar is located beneath the left main operation trocar with the interval
of at least 5 cm. See Chap. 2.
7.2.2 Exploration and Mobilization
After a comprehensive exploration of the abdominal organs, the location and size of
the tumor should be assessed meticulously (Figs. 7.1 and 7.2). The perihepatic liga-
ments are transected by harmonic scalpel from round ligament, falciform ligament,
left coronary ligament to left deltoid ligament in turn. The lesser omentum is tran-
sected with harmonic scalpel until the root of the ligamentum venosum with the left
lateral section lifted by the assistant.
exploration: a giant
hemangioma located in left
lateral section
7.2 Steps 53
exploration: a
hepatocellular carcinoma
located in left lateral
section

the left coronary ligament
The round ligament can be transected directly by harmonic scalpel or LigaSure,

without ligation of the both stumps. The transection should be close to the abdomi-
nal wall. This will help the traction of the liver from the near end without distur-
bance from the far end.
The second porta hepatis will be exposed after dissection of the suprahepatic
ligament. The left inferior phrenic vein drains into the IVC-near right margin of the
left coronary ligament, which should be carefully dissected in case of injury.
The transection of the left coronary ligament should start from the middle part
and move to the two sides. The over traction of the left deltoid ligament during
transection may cause the injury on the diaphragm. The resection line should be
close to the liver (Figs. 7.3 and 7.4).
The left lateral section should be drawn to the cranial and lateral direction
when the less omentum is dissected. The less omentum should be transected com-
pletely in order to introduce the staple passing the visceral surface of the liver
(Fig. 7.5).

the left deltoid ligament

the less omentum
7.2.3 Rough Dissection of the Portal Pedicles of Segments 2 and 3
The “vessel-less” parenchyma around the portal pedicles of the segments 2 and 3
are roughly dissected to expose the pedicles. Once the linear staple could be used,
the dissection should stop (Fig. 7.6).
7.2.4 Transection of the Portal Pedicles of Segments 2 and 3
The linear staple is introduced from the right auxiliary 12 mm trocar and the portal
pedicles of the segments 2 and 3 are then transected including the adhesive liver
parenchyma. This operation should be performed under direct vision to make sure
the entire portal pedicles of the segments 2 and 3 are transected (Fig. 7.7).
7.2 Steps 55
Fig. 7.6 The rough

dissection of the portal
pedicles of the segments
2 and 3
Fig. 7.7 The transection

of the portal pedicles of the
segments 2 and 3
7.2.5 Dissection of the Deep Parenchyma to Expose LHV
The parenchyma around the LHV are roughly dissected until the staple can contain
the remnant liver tissue including the root of the LHV (Fig. 7.8).
7.2.6 Transection of the Left Hepatic Vein
The stump of left deltoid ligament is grasped by the assistant to the anterior and
inferior direction. The two tips of the staple should be exposed to make sure the
LHV is transected entirely. The LHV is transected including the adhesive liver
parenchyma. The injury of the diaphragm and the IVC should be avoided by the
staples (Fig. 7.9).
Fig. 7.8 Dissection of the

deep parenchyma to
expose the LHV

the left hepatic vein
When the LHV is not totally transected, an absorbable clip should be used to
clamp the stump of the LHV. Then the residual tissue could be dissected by scissors
or harmonic scalpel. The metal nails in the staple might damage the harmonic
scalpel (Fig. 7.10).
7.2.7 Hemostasis and Drainage
The argon beam is used for errhysis of the raw surface. The Biclamp is used for
gentle active bleeding. The absorbable clips are used for obvious active bleeding.
The suture is used for bile leak and the bleeding impossible to be controlled by other
means (Figs. 7.11 and 7.12).
7.2 Steps 57
Fig. 7.10 The LHV is not

totally transected
Fig. 7.11 The argon beam

for errhysis
Fig. 7.12 Postoperative
drainage
7.2.8 To Withdraw Specimen
The benign tumor specimen could be withdrawn from the expanded umbilical inci-
sion after fragmentation. The malignant specimen should be withdrawn as a whole
in case of possible dissemination. There are four approaches to withdraw the speci-
men: (a) through the incision between the main and auxiliary operational holes; (b)
through the scar of the previous surgery; (c) through a new incision above the sym-
physis pubis; (d) through the vaginal fornix incision.
7.3 Key Techniques
1 . The intraoperative vascular occlusion and dissection of the LHV are needless.
2. The full mobilization of the lateral liver section is the key for the safe use of the
staple.
3. The portal pedicles of the segments 2 and 3 are roughly dissected.
4. The dissection line of the deep parenchyma to expose the LHV should be a little
bit to the left so that the LHV could be ligated entirely.
7.4 Complications
1. The intraoperative and postoperative complications can be managed similarly to

those of laparoscopic partial hepatectomy.
2. For the arteries and portal bleeding, “the three-step hemostasis method” could be
used after the control of the vision by the suction and compression of the gauze.
Firstly, the Biclamp is used to coagulate. Secondly, the absorbable clip, titanium
clip or Hem-o-lok is used on the target vessel. Thirdly, laparoscopic suture is the
last step before conversion.
3. The hepatic vein bleeding should be managed with great caution to avoid gas
embolism. For partial hepatic vein fracture, the clip or staple is preferable. When
the stump of the hepatic vein has shrunk into the liver parenchyma, the
coagulation may not work. After the control of the vision by the suction and
gauze, the surgeon should try to grasp the stump and then use the clip or suture
to fix the fracture. The repeating trying in a short time is not wise.
7.5 Notes
1. The gastrointestinal decompression and ureteral catheterization can stop on the

first postoperative day. The patient can intake liquid diet. After 3–5 days, the
patient can be discharged.
2. The second surgery can also be performed laparoscopically for the uncontrolla-
ble postoperative abdominal bleeding.
Laparoscopic Left Hepatectomy
8
Abstract
Left semi-liver contains the segments 2, 3, and 4. There are some similarities
between laparoscopic and open left hepatectomy. They both belong to the ana-
tomic liver resection. They both need dissection of the first hilum to control the
inflow blood. However, the outflow of the hepatic vein can be difficult to occlude
in an extra-hepatic way before the parenchyma dissection laparoscopically. It
also could be transected along with the parenchyma dissection. Laparoscopic left
hepatectomy is still challenging and demanding surgery.
Left semi-liver contains the segments 2, 3, and 4. There are some similarities
between laparoscopic and open left hepatectomy. They both belong to the anatomic
liver resection. They both need dissection of the first hilum to control the inflow
blood. However, the outflow of the hepatic vein can be difficult to occlude in an
extra-hepatic way before the parenchyma dissection laparoscopically. It also could
be transected along with the parenchyma dissection. Laparoscopic left hepatectomy
is still challenging and demanding surgery.
8.1.1 Indications
1. Lesion located limitedly in the segments 2, 3, and 4 while less resection is

inappropriate.
2. The first and second porta hepatis could be manipulated. Malignant tumor, diam-
eter ≤10 cm; or benign tumor, diameter ≤15 cm.
3. Liver function of Child B or better
4. Donor of the living liver transplantation

https://doi.org/10.1007/978-94-017-9735-1_8
60 8 Laparoscopic Left Hepatectomy
1 . Compression or infiltration to the first or second porta hepatis;

2. Lymphadenectomy is needed for the metastatic lymphatic lesions. Embolectomy
is needed for the cancer thrombus in the bile duct, portal vein or inferior vena cava;
4. The general condition is too poor to tolerate pneumoperitoneum or general
anesthesia.
8.2 Steps
The supine position is taken. The operational table should be adjusted according to
the intraoperative needs. See Chap. 2 for trocar distribution.
8.2.2 Exploration and Mobilization
After a comprehensive exploration of the abdominal organs, the location and size of the
tumor should be assessed meticulously. The key points of the tumor include location,
size, number, possible metastasis lesions and the level of liver cirrhosis. The laparoscopic
ultrasonography will help to decide the resectability and alternative surgical plans.
The order to mobilize left semi-liver is round ligament, falciform ligament, left
coronary ligament and part of right coronary ligament, left deltoid ligament, and
then hepatogastric ligament.
The left part of the right coronary ligament should be incised to make the right
turn-over of the left semi-liver possible to access (Fig. 8.1).
Fig. 8.1 The left part of

the right coronary ligament
is incised
8.2 Steps 61
8.2.3 Dissection of First Hilum and Control of Inflow Blood
The left liver artery can be dissected out by the intra-fascial approach. The right
posterior artery originating from the left liver artery should be noticed. The dis-
section should be close to the liver parenchyma to the maximum extent. Through
the Glissonean pedicle approach, the left liver artery and portal vein can be tran-
sected at the same time (Figs. 8.2 and 8.3). We usually transect the left portal
pedicles after dissection of the superficial liver parenchyma (Figs. 8.4 and 8.5)
(see Sect. 8.2.5).

left liver artery (The hilar
access approach)

left portal vein (The hilar
access approach)

the left portal pedicles by
staple
Fig. 8.5 After transection

of the left portal pedicles
8.2.4 Exposure of Second Hilum and Control of Outflow Blood
For minor hepatectomy, the LHV should be dissected out without ligation (Fig. 8.6).
For major hepatectomy, the LHV should be ligated without transection, mainly con-
sidering the possible bleeding from the hepatic vein.
8.2.5 Parenchymal Dissection
According to the ischemic demarcation (Fig. 8.7), the liver parenchyma is dissected

by harmonica scalpel and linear staple (Fig. 8.8). The Biclamp and clips are used
against bleeding from the cutting. The titanium clip should be avoided, because the
occlusal strength is less than the other advanced clips (Fig. 8.9). The dysfunction of
the titanium clip may cause unnecessary bleeding. Meanwhile, its existence may
have an inconvenient effect on the subsequent operation.
8.2 Steps 63
Fig. 8.6 Exposure of the

LHV
Fig. 8.7 The ischemic line

of the liver surface
Fig. 8.8 The superficial

parenchyma is dissected by
harmonic scalpel
Fig. 8.9 The absorbable

chip for the vessels in raw
surface

the LHV
8.2.6 Transection of LHV
The angle and direction of the staple should be carefully chosen when the LHV is
transected. The direction of the staple should point to the root of the LHV, even
slightly left when necessary, so as to avoid the injury of the MHV (Fig. 8.10). The
preoperative images should be thoroughly studied to clarify the relationship between
the LHV and MHV. The two tips of the staple should be exposed in vision to avoid
the diaphragm injury.
When the LHV is not totally transected, an absorbable clip should be used to
clamp the stump of the LHV (Fig. 8.11).
8.2.7 Hemostasis
The argon beam is used for errhysis of the raw surface (Fig. 8.12). The Biclamp is
used for gentle active bleeding. The absorbable clips are used for obvious active
8.2 Steps 65
Fig. 8.11 Management of

partial transection of the
LHV
Fig. 8.12 Hemostasis in

the raw surface
bleeding. The suture is used for bile leak and the bleeding impossible to be controlled
by other means.
The specimen is withdrawn with an endoscopic retriever through the expanded inci-
sion. It should be inspected immediately.
8.2.9 Drainage
The drainage tube is placed on the raw surface of the liver (Fig. 8.13).
Fig. 8.13 Drainage
8.3 Key Techniques
1. The main operational trocar should be placed carefully. It should not only be
convenient for the mobilization and parenchyma transection, but also make the
staple through the trocar easy to point along the planned liver cutting plane.
2. The liver should be fully mobilized, especially for the hepatogastric ligament.
The hepatogastric ligament should be transected from the root of the LHV to the
foramen of Winslow. This will help the exposure of the LHV and introduction of
the staple to transect the left portal pedicles.
3. To avoid the injury of the MHV, the direction of the staple should point to the
root of the LHV, even slightly left when necessary.
4. When the intraoperative bleeding is over 800 ml, conversion to open surgery
should be taken immediately.
8.4 Complications
The intraoperative and postoperative complications can be managed similarly to

those of laparoscopic lateral sectionectomy. Also see discussion in Chap. 1.
8.5 Notes
1. The gastrointestinal decompression and ureteral catheterization can stop on the

first postoperative day. The patient can intake liquid diet. After 3–5 days, the
patient can be discharged.
2. The second surgery can also be performed laparoscopically for the uncontrolla-
ble postoperative abdominal bleeding.
Laparoscopic Right Posterior
Sectionectomy 9
Abstract
Right posterior section contains the segments 6 and 7. The portal pedicles of the
right posterior section can be easily dissected out, because they lie superficially
in the right fissure of the hilum.
Right posterior section contains the segments 6 and 7. The portal pedicles of the
right posterior section can be easily dissected out, because they lie superficially in
the right fissure of the hilum.
9.1.1 Indications
1. Lesion located limitedly in the segments 6 and 7 while less resection is

inappropriate.
2. The first and second porta hepatis could be manipulated. Malignant tumor, diam-
eter ≤10 cm; or benign tumor, diameter ≤15 cm.
3. Liver function of Child B or better.
4. No portal thrombus; No intrahepatic or systemic metastasis.
1 . The invasion to the IVC or the root of RHV;

2. Lymphadenectomy is needed for the metastatic lymphatic lesions. Embolectomy
is needed for the cancer thrombus in the bile duct, portal vein or inferior vena cava;
4. The general condition is too poor to tolerate pneumoperitoneum or general
anesthesia

https://doi.org/10.1007/978-94-017-9735-1_9
68 9 Laparoscopic Right Posterior Sectionectomy
9.2 Steps
The left lateral position is taken. The operational table should be adjusted according
to the intraoperative needs. See Chap. 2 for trocar distribution.
9.2.2 Exploration
Laparoscopic abdominal exploration is performed comprehensively and combined

with the preoperative imaging (Fig. 9.1). The location, size, and number of the
tumor should be inspected meticulously. The laparoscopic ultrasonography could
further provide the information such as the main feeding vessels of the tumor,
existence of the satellite focus, and accurate boundaries of the tumor.
9.2.3 Mobilization
The right perihepatic ligament should be dissected as much as possible (Fig. 9.2).

The ligament of left vena cava should also be transected for the convenience of
lifting the right section during the surgery.
Fig. 9.1 Exploration of

the right posterior section
9.2 Steps 69
9.2.4 Dissection and Control of Inflow Blood
There is no visible boundary of the right posterior section on the surface of the liver
(Fig. 9.3). Identification of the right posterior portal pedicle is the key to perform
sectionectomy safely (Fig. 9.3). Once occluded, the ischemic line could be the guid-
ance for the parenchyma dissection (Figs. 9.3 and 9.4).
Fig. 9.2 The transection

of the ligament of left vena
cava

superficial parenchyma of
the right posterior section
with harmonic scalpel
70 9 Laparoscopic Right Posterior Sectionectomy
Fig. 9.4 Transection of the

right posterior portal
pedicels
Fig. 9.5 Hemostasis in the

raw surface
9.2.5 Control of Outflow Blood
There is no need for isolation of the hepatic vein of the right posterior section before
the parenchyma dissection. For those with great risk of intraoperative bleeding, the
second hilum should be clearly dissected without ligation. The hepatic vein of the
right posterior section could be transected along with the parenchyma or clipped
individually.
9.2.6 Hemostasis
The argon beam is used for errhysis of the raw surface (Fig. 9.5). The Biclamp is
used for gentle active bleeding. The absorbable clips are used for obvious active
bleeding. The suture is used for bile leak and the bleeding impossible to be controlled
by other means.
9.5 Notes 71
Fig. 9.6 The specimen
The specimen is withdrawn with an endoscopic retriever through the expanded inci-
sion. It should be inspected immediately (Fig. 9.6).
9.2.8 Drainage
The two drainage tubes are placed on the raw surface of the liver and the foramen of
Winslow, respectively.
9.3 Key Techniques
1. Bleeding. The first hilum should be well prepared in case of the need for Pringle
maneuver. The timely conversion is a wise surgical strategy.
2. Bile leak. The absorbable clip or Hom-o-Lok should be used before transection
of the bile ducts on the raw surface.
9.4 Complications
The intraoperative and postoperative complications can be managed similarly to

those of laparoscopic lateral sectionectomy. Also see discussion in Chap. 1.
9.5 Notes
The gastrointestinal decompression and ureteral catheterization can stop on the first
postoperative day. The patient can intake liquid diet. After 3–5 days, the patient can
be discharged.
Retroperitoneal Laparoscopic
Hepatectomy 10
Abstract
As a novel operation, retroperitoneal laparoscopic hepatectomy was conducted
first by Dr. Liu Rong (Hu et al. 2011). It is a new option of liver minimal invasive
surgeries.
As a novel operation, retroperitoneal laparoscopic hepatectomy was conducted first

by Dr. Liu Rong (Hu et al. 2011). It is a new option of liver minimal invasive
surgeries.
10.1 Indications
The right posterior section of the liver is closely adhesive to the posterior abdominal
wall, with an adjacent relationship with the kidney, right adrenal gland, and IVC. The
dissection in this potential plane can damage the hepatic short vein and parenchyma,
causing bleeding. Enlightened by urological surgery, the access could directly reach
the right back of the liver retroperitoneally. The primary clinical practices have
showed that it is safe and feasible and also expands the indications of laparoscopic
hepatectomy to some extent.
However, the indications for retroperitoneal laparoscopic hepatectomy are quite
narrow: the superficial tumor located in the right posterior section with a diameter
of ≤3 cm. Laparoscopic exploration of the abdominal cavity is impossible to
perform with this approach. For those patients with severe abdominal adhesions,
this approach may be a preferable alternative (Fig. 10.1).

https://doi.org/10.1007/978-94-017-9735-1_10
74 10 Retroperitoneal Laparoscopic Hepatectomy
Fig. 10.1 Indications for

the retroperitoneal
laparoscopic hepatectomy
Fig. 10.2 Position of the patient (anterior)
10.2 Steps
The patient is in the left lateral recumbent position (Figs. 10.2 and 10.3). The pneu-
moperitoneum pressure is set at 14 mmHg.
The first trocar (10 mm) is placed using the same method as that of retroperito-
neal laparoscopic adrenalectomy. Three additional trocars are then placed at 10 mm
above the iliac crest in the midaxillary line (observation port), at 12 mm below the
costal margin of the 11th rib on the anterior axillary line, and at 5 mm below the
costal margin of the 12th rib on the posterior axillary line, respectively.
After the retroperitoneal space is established, the retroperitoneal fat tissue is dis-
sociated from top to bottom. The lateroconal fascia and perinephric fascias are
exposed. The perinephric space is opened by dissection of the lateroconal fascia and
perinephric fascias at the peritoneal reflection. The perirenal fat capsule is divided
along the prerenal fascia and then the perinephric space is expanded (Fig. 10.4).
The liver lies on the top of the perinephric space and anterior to the right adrenal
gland (Fig. 10.5). The segment 6 can be exposed once the peritoneum is dissected.
The tumor is removed by harmonica scalpel (Figs. 10.6 and 10.7).
10.2 Steps 75
Fig. 10.3 Position of the patient (posterior)
Fig. 10.4 Dissection of

the perirenal fat
Fig. 10.5 The liver lies on

the top of the perinephric
space
76 10 Retroperitoneal Laparoscopic Hepatectomy
Fig. 10.6 The tumor is

removed by harmonica
scalpel
Reference
Hu M, et al. Retroperitoneal laparoscopic hepatectomy: a novel approach. Surg Laparosc Endosc
Percutan Tech. 2011;21(5):e245–8.
Laparoscopic Right Hepatectomy
11
Abstract
Although the laparoscopic left lateral liver resection has been deemed as a gold
standard procedure for liver lesions located in segments II and III, totally laparo-
scopic hemihepatectomy, especially laparoscopic right hepatectomy (LRH) is
still a challenging and technically demanding surgery, with a high rate of conver-
sion. There is general agreement that this surgery should be performed only at
specialized centers with extensive experience in hepatic surgery and advanced
laparoscopic technique, to ensure patients’ safety and strict adherence to estab-
lished surgical indications. Our team has experience in performing laparoscopic
hepatectomy for over 10 years. After establishing stylized method for laparo-
scopic right hemihepatectomy (LRH), we had accomplished 21 totally laparo-
scopic right hepatectomy from 2011 to 2014. In this chapter, we describe our
technique for stylized method of laparoscopic right hepatectomy, highlighting
the most relevant technical details essential for accomplishing a safe and effi-
cient procedure. We also discuss the indications of increasing experience and
improved skills developing during this time.
Although the laparoscopic left lateral liver resection has been deemed as a gold
standard procedure for liver lesions located in segments II and III, totally laparo-
scopic hemihepatectomy, especially laparoscopic right hepatectomy (LRH) is still
a challenging and technically demanding surgery, with a high rate of conversion.
There is general agreement that this surgery should be performed only at special-
ized centers with extensive experience in hepatic surgery and advanced laparo-
scopic technique, to ensure patients’ safety and strict adherence to established
surgical indications. Our team has experience in performing laparoscopic hepatec-
tomy for over 10 years. After establishing stylized method for laparoscopic right
hemihepatectomy (LRH), we had accomplished 21 totally laparoscopic right

https://doi.org/10.1007/978-94-017-9735-1_11
78 11 Laparoscopic Right Hepatectomy
hepatectomy from 2011 to 2014. In this chapter, we describe our technique for
stylized method of laparoscopic right hepatectomy, highlighting the most relevant
technical details essential for accomplishing a safe and efficient procedure. We
also discuss the indications of increasing experience and improved skills develop-
ing during this time.
Patients’ general conditions should not compromise the safety of the anesthe-
sia, and ASA classification (American Society of Anesthesiologists’ Physical
Status Classification) should be at 3 or below. The preoperative investigations
of lesion included liver imaging (spiral computed tomography or magnetic res-
onance imaging). For patients with cirrhosis undergoing major hepatectomy,
Child-Pugh classification, the ICG (indocyanine green) clearance test, and com-
puted tomography volumetry are helpful in evaluating whether the remnant liver
volume is adequate.
The indications for LRH are similar to those for open liver resection with the
same oncologic rules, including “no-touch” tumor technique, radical R0 resection,
and a free surgical margin. Benign or malignant lesions located in the right lobe of
the liver, involving the Segment 5–8 or adjacent to main inflow/outflow vessels of
the right lobe of liver are considered suitable for right hepatectomy.
The need for vascular or biliary reconstruction is currently a contraindication to
the laparoscopic approach. Preoperative imaging or intraoperative ultrasonography
that fails to delineate the location of the lesion clearly or could not obtain a negative
resection margin should be considered a relative contraindication. Previous abdomi-
nal surgery history increases the likelihood of conversion, but is not a contraindica-
tion to the minimally invasive approach.
11.2 Procedure
11.2.1 Patient’s Position and Trocar Arrangement
Under general anesthesia, the patient is placed in left lateral semi-decubitus position
with the right arm suspended. A Veress needle is inserted 5 cm right of the midline
at the level of the umbilicus and the peritoneal cavity is insufflated to a pneumoperi-
toneum with a pressure of 15 mmHg and the Veress needle is withdrawn. The lapa-
roscopic camera is inserted through the trocar at the puncture point of Veress needle.
Three or four working trocars are placed along the line just beneath the costal arch.
One of them is the 12-mm key working trocar, which would be used to handle the
endostapler, and the other assistant trocars are placed at intervals of 8–10 cm next to
that. Selection of every point to insert trocar should depend on the liver’s shape, key
anatomy structure, and decreasing the mutual interference of the instruments during
the operation.
11.2 Procedure 79
11.2.2 Laparoscopic Ultrasonography
We use the Pro Focus 2202 Ultrasound Scanner system with Laparoscopic Transducer
(Fig. 11.1). The procedure of intraoperative ultrasound (IOUS) is as follows: (1)
Screen the entire liver to rule out any satellite nodule of HCC; (2) Identify surgical
resection margin; (3) Assess the anatomical structures such as vascular and biliary
branches in order to accomplish anatomical resections.
11.2.3 Mobilization of the Right Lobe
We first divide the round and falciform ligaments to the level of the second porta
hepatis (Fig. 11.2). Then completely divide the right triangular and coronary
ligaments, and the bare area of the right lobe is mobilized completely (Fig. 11.3).
The inferior vena cava is dissected and small accessory hepatic veins can be
controlled with Hem-o-lok surgical clips (Fig. 11.4). The right hepatic vein
(RHV) is exposed and the retrocaval ligament is divided to allow access to the
right side of the vein, when the right hepatic vein cannot be dissected safely from
an extrahepatic approach, this dissection should be completed within the liver
parenchyma.
a b
Fig. 11.1 The laparoscopic ultrasound transducer. (a) the general view of the transducer; (b) the
guiding tunnel of the transducer

the round and falciform
ligaments

the right triangular and
coronary ligaments

small accessory hepatic
veins
11.2.4 Control of the Inflow/Outflow Vessels
After cholecystectomy, hilar dissection is performed to free the right Glisson’s ped-
icle. Firstly, the right hepatic artery is identified, ligated, and transected (Fig. 11.5).
Secondly, the portal vein is traced until the bifurcating into its right or left branch,
then the right branch of portal vein is ligated but not transected to obstruction inflow
(Fig. 11.6). CT angiography is a useful way to evaluate the variation of right portal
vein before the operation.
Normally, we should not attempt to dissect and expose the right hepatic vein
extraparenchymally, because handling the bleeding of RHV laparoscopically is very
difficult and has the potential risk of gas embolism (Fig. 11.7). If there are no thick
11.2 Procedure 81
Fig. 11.5 (a, b) Ligation

and transection of the a
right hepatic artery
tributaries near the root of RHV and the surrounding tissue of the RHV could be
identified and dissected free easily, the root of the RHV is fully exposed from the
anterocranial and the posterior aspects by dividing the right retrocaval ligament.
The RHV itself is transected with endostapler until the accomplishment of the
parenchymal division. Experienced surgeon could divide RHV and hang it with sili-
con tube or a cotton tape that could control the massive bleeding of the RHV during
the transection of the hepatic parenchyma.
11.2.5 Transection of the Hepatic Parenchyma
The superficial hepatic parenchyma is transected using the Harmonic Scalpel

(Ethicon, Cincinnati, OH, USA) or the THUNDERBEAT (Olympus, Tokyo, Japan)
(Figs. 11.8 and 11.9), the deeper portion of the parenchyma is dissected combined
with the BiClamp® forceps of Electronic Surgical Workstation and Argon beam
coagulation to achieve venous hemostasis (Fig. 11.10). Bipolar coagulating/cutting
Fig. 11.6 (a, b) Ligation

and transection of the a
right branch of portal vein
Fig. 11.7 Dissection and

exposion of the RHV
11.2 Procedure 83
Fig. 11.8 The ischemic line

of the liver surface

superficial hepatic
parenchyma
Fig. 11.10 Transection
and hemostasis of the
deeper portion of the
parenchyma
device (LigaSure, Valley Laboratory, Boulder, CO) is an instrument of choice to

seal vessels that are less than 7 mm (e.g., small venous branches or glissonian
pedicle). The plane of dissection should be slightly “open” faced to camera by the
assistant to obtaining good views. Laparoscopic cavitron ultrasonic dissector can
be used to transect the parenchyma also. Lapro-Clip™ absorbable clip or Hem-o-
lok is used to transect vessels and bile ducts up to 12 mm (Fig. 11.11). Endoscopic
articulating linear cutter (such as Echelon, Ethicon, Endo-Surgery) facilitates divi-
sion of larger vessels (right hepatic vein or right hepatic pedicle) (Figs. 11.12 and
11.13).
Fig. 11.11 The absorbable

chip for the vessels in raw
surface

the right portal pedicels
11.2 Procedure 85
Fig. 11.13 Transection
of the right hepatic vein
11.2.6 Specimen Retrieval and Drainage
The specimen is removed in a plastic bag (Endocatch; Ethicon Endo-Surgery)

introduced through one of 12-mm ports which is subsequently extended to a
7–10 cm incision.
After retrieving the specimen (Fig. 11.14), the raw surface of the liver is exam-
ined carefully for bleeding and bile leak. Hemostasis is obtained using BiClamp®
forceps of Electronic Surgical Workstation and Argon beam coagulation (Fig. 11.15).
Bile leak is controlled with Prolene 4/0 stitches or with clips. A 20Fr silicon tube
drain is positioned near the resection surface.

the raw surface by Argon
beam coagulation
11.3 Key Techniques
Left lateral semi-decubitus position with the right arm suspended has several privi-
leges for the hepatectomy: Firstly, with this position surgeon could view the hilum
from the right posterior side that makes the hilar dissection more accurate. Secondly,
the weight of the liver makes the right lobe naturally falls to the left, which helps to
dissect the coronary and right triangular ligaments. Thirdly, transection plane could
be easily kept to face the camera.
The ultrasonic dissector is mainly applied to perform tissue dissection and
hemostasis while the BiClamp® forceps in the left hand provide retraction and res-
cue hemostasis. BiClamp® forceps have been very useful for hemostasis and coagu-
lation of liver parenchyma and small vessels (<4 mm). The assistant should keep
the surgical field clean and visualize the bleeding point with suction. The transec-
tion of parenchyma should be advanced layer after layer. That is important to avoid
tunneling into the hepatic parenchyma accidently, thus creating deep holes where
the view is compromised and bleeding control is difficult. The active blade of ultra-
sonic shears have a potential risk of massive bleeding by direct injury of the wall
of hepatic veins, so that it is better to avoid exposure of the major trunk of middle
hepatic vein on the transection plane. Accurate anatomic selection of transection
plane requires the help of ultrasonography. Bleeding from injury on the venous
wall can usually be managed by direct compression with gauze pad and “close” the
transection surface and be careful not to coagulate blindly. Major injury of hepatic
vein trunk should be sutured and stumps of thick tributaries should be clipped.
Recent studies suggest that critical gas embolism is unlikely to occur as long as the
liver parenchyma is dissected under carbon dioxide insufflation at pressure below
12 mmHg.
11.5 Notes 87
11.4 Complications
Bleeding is always the most important issue in laparoscopic hepatectomy and it is

the most frequent reason that causes fear among surgeons. Thus, surgeons who per-
form laparoscopic right hepatic resection should be familiar with the laparoscopic
anatomy of the liver and laparoscopic suturing. After retrieving the specimen, the
raw surface of liver should be examined carefully for bleeding and bile leak.
Laparotomy is the ultimate and most effective way to control the bleeding.
Symptomatic pleural effusion could be managed conservatively without the need
for additional surgery.
11.5 Notes
Be careful of the volume and characteristics of drainage fluid. The gastrointestinal

decompression can stop after 6–8 hours and the patient can intake liquid diet.
Laparoscopic Caudate Lobectomy
12
Abstract
Caudate lobe is surrounded by most major vessels of the liver, which makes lapa-
roscopic hepatectomy of caudate lobe more complex and potentially more dan-
gerous than other hepatic segmentectomy. Such dangerous procedures should
be performed by surgeons who have advanced experiences both in open and
minimally invasive liver resection. The caudate lobe is the dorsal portion of the
liver and half encircles the IVC, and it is composed of three parts: Spiegel lobe
lies to the left side of IVC; the paracaval portion lies anterior to the IVC, and the
caudate process is located between the posterior branch of the right Glissonian
and IVC. Safe laparoscopic resection of caudate lobe requires mobilization and
control of the inflow/outflow vessels of the caudate lobe.
Caudate lobe is surrounded by most major vessels of the liver, which makes laparo-
scopic hepatectomy of caudate lobe more complex and potentially more dangerous
than other hepatic segmentectomy. Such dangerous procedures should be performed
by surgeons who have advanced experiences both in open and minimally invasive
liver resection. The caudate lobe is the dorsal portion of the liver and half encircles
the IVC, and it is composed of three parts: Spiegel lobe lies to the left side of IVC;
the paracaval portion lies anterior to the IVC, and the caudate process is located
between the posterior branch of the right Glissonian and IVC. Safe laparoscopic
resection of caudate lobe requires mobilization and control of the inflow/outflow
vessels of the caudate lobe.

https://doi.org/10.1007/978-94-017-9735-1_12
90 12 Laparoscopic Caudate Lobectomy
Symptomatic benign tumors or malignant tumors in the caudate lobe are indications
for laparoscopic caudate lobectomy. For the anatomical features of caudate lobe, the
lesions that are amenable for laparoscopic resection are mostly located in the
Spiegel lobe and caudate process.
Contraindications for laparoscopic caudate resection include portal vein/IVC
invasion, large tumor volume, and insufficient experience of the surgeon.
12.2 Procedure
12.2.1 Laparoscopic Hepatectomy of Spiegel Lobe
12.2.1.1 Patient’s Position and Trocar Arrangement

Under general anesthesia, the patient is placed in supine position. A Veress needle
is inserted below the umbilicus. Then the peritoneal cavity is insufflated to a pneu-
moperitoneum with a pressure of 13 mmHg and the Veress needle is withdrawn. A
trocar for the laparoscopic camera is inserted through the same incision. Three or
four working trocars are placed along the line just beneath the costal arch. One of
them is the 12-mm key working trocar, which would be used to handle the endosta-
pler, and the other assist trocars are placed at intervals of 8–10 cm next to that. The
trocar arrangement should depend on the liver’s shape and key anatomy structure,
while decreasing the mutual interference of the instruments during the operation.
12.2.1.2 Mobilization
We first divide the round ligament and take down the falciform ligaments from the
abdominal wall to the confluence of the hepatic veins and vena cava. The round liga-
ment should be transected close to the abdominal wall as to avoid interfering the
view by its dangling remnant. Then the left triangular and coronary ligaments are
divided completely (Fig. 12.1), and subsequently the assistant can retract the left
lateral lobe and divided the lesser omentum, so that the speigel lobe can be exposed
(Fig. 12.2). IVC is dissected and small accessory hepatic veins can be controlled
with Hem-o-lok surgical clips (Fig. 12.3). During the whole period of operation,
surgeon should be very careful of these clips and fall off any one of them may cause
bleeding. When the left hepatocaval ligament is divided and the Spiegel lobe mobi-
lized away from IVC, the root of LHV is exposed (Fig. 12.4).
Hilar dissection is performed to free the left Glisson’s pedicle. The caudate
branches of the left portal vein and hepatic artery are dissected and transection by
the Hem-o-lok or absorbable clip (Fig. 12.5).
12.2.1.3 Transection of the Hepatic Parenchyma

The isthmus of the caudate lobe is transected using the Harmonic Scalpel combined
with the bipolar forceps (Fig. 12.6). Then absorbable clip or endoscopic articulating
linear cutter is used to transect the parenchyma depending on the thickness of isth-
mus. It should be very careful to avoid the injury of HV/IVC by the tip of linear
cutter.
12.2 Procedure 91
Fig. 12.1 Mobilization
the left triangular and
coronary ligaments
Fig. 12.2 Exposure of

the speigel lobe

the IVC
Fig. 12.4 Exposure of

the root of LHV

the caudate branches of
the left portal vein

the hepatic parenchyma
12.2 Procedure 93

the raw surface
12.2.1.4 Specimen Retrieval and Drainage

The specimen is removed in a plastic bag (Endocatch; Ethicon Endo-Surgery) intro-
duced through one of 12-mm ports subsequently extended to a 7–10 cm incision.
After retrieving the specimen, the raw surface of the liver is examined carefully
for bleeding and bile leak. Hemostasis is obtained using BiClamp® forceps of
Electronic Surgical Workstation and Argon beam coagulation (Fig. 12.7). Bile leak
is controlled with Prolene 4/0 stitches or with clips. A 20Fr silicon tube drain is
positioned near the resection surface.
12.2.2 Laparoscopic Hepatectomy of Caudate Process
Only specific lesions in the caudate process are amenable to laparoscopic resection.
We have performed the laparoscopic hepatectomy of the caudate process as follows:
12.2.2.1 Patient’s Position and Trocar Arrangement

The patient is placed in the supine position. Arrangements of trocar are same with
that of the laparoscopic right hepatectomy, and three working trocars were placed
along the line just beneath the costal arch.
12.2.2.2 Mobilization
We first divide the small accessory hepatic veins and mobilized the lesion. The
small hepatic veins can be controlled with Hem-o-lok surgical clips or absorbable
clips.
12.2.2.3 Transection of the Hepatic Parenchyma

The parenchyma is transected using the Harmonic Scalpel combined with the bipo-
lar forceps. Then absorbable clips are used to control the vessels of lesion.
12.2.2.4 Specimen Retrieval and Drainage

The specimen is removed in a plastic bag (Endocatch; Ethicon Endo-Surgery) intro-
duced through one of 12-mm ports.
After retrieving the specimen, the raw surface of liver is examined carefully
for bleeding. Hemostasis is obtained using BiClamp® forceps or Argon beam
coagulation.
12.3 Key Techniques
Mobilization is the key step for the laparoscopic caudate lobectomy, and surgeon
should have enough experience in handing the small hepatic vein.
12.4 Complications
IVC/HV bleeding is the most dangerous issue in laparoscopic hepatectomy of cau-

date lobe and has potential risk of gas embolism. Thus, surgeons who perform lapa-
roscopic hepatic caudate lobe resection should be familiar with the laparoscopic
anatomy of the liver and laparoscopic suturing. If the bleeding is difficult to handle,
surgeon should take temporary measures for bleeding control if possible, and the
conversion to laparotomy must be performed without hesitation.
12.5 Notes
Pay attention to observe the drainage fluid and in case of hemorrhage or bile
leakage.
Radiofrequency Ablation Assisted
Laparoscopic Hepatectomy 13
Abstract
As is introduced in the above chapters, despite advances in surgical technique,
due to poor hepatic reserve, portal hypertension and other conditions that patients
with concomitant cirrhosis may have, laparoscopic liver resection may be
encountered with considerable intraoperative blood loss, which is why it is
essential to develop techniques that can reduce blood loss during liver parenchy-
mal resection. Radiofrequency ablation (RFA), which had been proved to be able
to block small and medium-sized blood vessels (less than 5 mm in diameter) in
the liver through thermal coagulation, was used in liver resection to reduce bleed-
ing in the past years with satisfying results (Weber et al. 2002; Pai et al. 2008),
and thus has been recommended for cirrhotic patients. In this chapter, we will
discuss the indications and contraindications, operative steps, key techniques,
major complications as well as points should be noted of RFA assisted laparo-
scopic liver resection in this chapter.
As is introduced in the above chapters, despite advances in surgical technique, due

to poor hepatic reserve, portal hypertension and other conditions that patients with
concomitant cirrhosis may have, laparoscopic liver resection may be encountered
with considerable intraoperative blood loss, which is why it is essential to develop
techniques that can reduce blood loss during liver parenchymal resection.
Radiofrequency ablation (RFA), which had been proved to be able to block small
and medium-sized blood vessels (less than 5 mm in diameter) in the liver through
thermal coagulation, was used in liver resection to reduce bleeding in the past years
with satisfying results (Weber et al. 2002; Pai et al. 2008), and thus has been recom-
mended for cirrhotic patients. In this chapter, we will discuss the indications and
contraindications, operative steps, key techniques, major complications as well as
points should be noted of RFA assisted laparoscopic liver resection in this chapter.

https://doi.org/10.1007/978-94-017-9735-1_13
96 13 Radiofrequency Ablation Assisted Laparoscopic Hepatectomy
The following inclusion criteria are recommended:
1 . Resectable liver lesion or lesions with cirrhosis and adequate (R0) margins;
2. Hepatic function of Child-Pugh class A or B;
3. Adequate remaining functional liver parenchyma;
4. History of multiple TACE procedures.
5. Non-neoplastic lesions suitable for laparoscopic liver resection.
The following exclusion criteria were recommended:
1 . History of abdominal surgery;

2. Uncontrollable ascites, hepatic encephalopathy, or variceal bleeding;
3. Dysfunction of other organs;
4. Extrahepatic spread of disease;
5. Extremely impaired liver function (Child-Pugh class C).
13.2 Steps
1. The key technical points of patient positioning, preoperative preparation, anes-

thesia, ports placement, and the exploration of tumors are similar for radiofre-
quency assisted laparoscopic liver resection with conventional laparoscopic liver
resection, which has been introduced in detail in the above chapters. Laparoscopic
ultrasonography should be performed to have a sufficient understanding of the
number and location of the lesions, the detail of anatomical information of bili-
ary and vascular structures, and also the direction of the puncture of the needle
(Figs. 13.1, 13.2, and 13.3).
Fig. 13.1 Laparoscopic ultrasonography should be performed if necessary

13.2 Steps 97
Fig. 13.2 Laparoscopic ultrasonography demonstrating the detailed anatomical information of

biliary (white arrow) duct, hepatic artery (red arrow) and hepatic vascular (blue arrow)
Fig. 13.3 Laparoscopic ultrasonography demonstrating the direction of needle (arrow)
2. After laparoscopic scanning of the liver, the surgical tumor resection margins
can be demarcated. Generally, the margins should be kept 1 cm out the tumors,
and RFA was performed using a 17-G cooled-tip electrode with a 2-cm metallic
tip or 3-cm metallic tip (Figs. 13.4 and 13.5); the power was generally set to
60–80 W, and the coagulation time was usually 2–4 min. Bleeding vessels can be
treated with an extra procedure in purpose if necessary (Fig. 13.6). The angle of
Fig. 13.4 The RFA needle
Fig. 13.5 The RFA is being performed before resection of hepatic tumor
the puncture of RF needle is extremely important, and generally should be kept

similar with the following transection. After RFA, it can be hard to have a clear
imaging of the tumor any more. Generally, RFA should be performed 2–3 cm
each along the resection line, and sometimes a second application of RF ablation
is necessary to achieve sufficient coagulation. For deep tumors, the RF ablation
can be performed in the deepest part and then repeated after the needle tip is
withdrawn to the superficial area. If large vessels are encountered, it is extremely
important to reconsider the feasibility of the surgical plan. When the transection
plane is close to a major vessel, the RF ablation should be performed closer to
the vessel, with caution, in case the biliary structure or artery is injured.
13.2 Steps 99
Fig. 13.6 A bleeding vessel of hepatic cellular carcinoma
Fig. 13.7 Laparoscopic liver transection after RFA
3. Along the necrotic zone, laparoscopic liver transection can be achieved using an
ultrasonic dissector or other energy devices (Fig. 13.7) and the resected speci-
men can be placed in a plastic bag and removed, which has been introduced in
the previous chapters. During the operation, a formal hilar dissection and Pringle
maneuver is generally unnecessary. Primary dissection or second hilar dissection
was only done when the tumor was adjacent to the hepatic hilum or hepatic
veins. With the assistance of radiofrequency ablation, the operative blood loss
and transfusion rate can be minimized.
13.3 Key Techniques
1. A sufficient inspection using laparoscopic ultrasound to demarcate a rational and

feasible transection plane is extremely important, which should take the remnant
liver function, the encountered vessels, and the sufficiency of resection area into
account. Generally, the angle of the puncture of RF needle should be kept paral-
lel to the transection plane, which is why the puncture site should be carefully
selected.
2. Laparoscopic ultrasound is routinely used to locate the tumors. Generally,

hepatic cellular carcinoma appeared as hypo-echoic lesion (Fig. 13.8), and cir-
rhotic nodes appeared as hyper-echoic lesion with sharp margin which is usually
smaller than 1 cm (Fig. 13.9). Sometimes malignant tumor might appear as inho-
mogeneous echoic lesion or iso-echoic lesion with no clear margin, in which
case, contrast enhanced ultrasound is suggested for differential diagnosis
(Figs. 13.10 and 13.11).
3. When the location of tumor is very deep, RFA might cause heat injury of the
underneath structure such as the stomach and intestine. In this case, liver can be
lifted or stuffed with gauze to protect the adjacent tissue.
13.4 Complications
The RF ablation assisted laparoscopic liver resection is generally safe and feasible,
with very low complication rate. The major complications are as followed:
Fig. 13.8 Generally,
hepatic cellular carcinoma
appeared as hypo-echoic
lesion (arrow)
13.4 Complications 101
Fig. 13.9 Cirrhotic nodes

appeared as hyper-echoic
lesion with sharp margin
which is usually smaller
than 1 cm (arrow)
Fig. 13.10 Hepatic
cellular carcinoma
appeared as
inhomogeneous echoic
lesion (arrow)
1. Liver resection related complications, such as bleeding, bile leakage, and insuf-
ficient remnant hepatic function. The risk of bleeding and bile leakage of RFA
assisted laparoscopic liver resection is lower than that of conventional laparo-
scopic liver resection.
2. Heat injury of adjacent tissue, such as gallbladder, diaphragm, and gastrointesti-
nal tract.
3. Hepatic abscess.
4. Biliary injury.
5. Skin burn.
6. Hemoglobinuria.
13.5 Notes
1. During surgery, the coagulation area generally appeared as a hypoechoic area in

ultrasonography (Figs. 13.12 and 13.13).
Fig. 13.11 Contrast enhanced ultrasound revealed a hyper-enhanced lesion suggesting malignancy
Fig. 13.12 Coagulation
area appeared as a
hypoechoic area
References 103
Fig. 13.13 The hypoechoic area in conventional ultrasound appeared as non-contrast enhanced
area in contrast enhanced ultrasound (arrow)
2. The RFA assisted liver resection technique is useful for both open liver resection
and laparoscopic liver resection.
3. This technique can also be used in laparoscopic regular liver resection, which
can reduce the blood loss effectively.
4. The post-operative biochemistry results and the temperature should be paid
attention on.
References
Pai M, et al. Liver resection with bipolar radiofrequency device: Habib™ 4X. HPB (Oxford).
2008;10(4):256–60.
Weber JC, et al. New technique for liver resection using heat coagulative necrosis. Ann Surg.
2002;236(5):560–3.
Index
A indications, 29
Anesthesia, 28 monopolar electrocoagulation, 30
position and trocars’ locations, 30
postoperative attentions, 33
B ultrasonic dissector, 30
BiClamp® forceps, 81, 83, 84, 93, 94
F
C Focal nodular hyperplasia (FNH), 46
Caudate lobectomy
of Caudate process
hemostasis, 94 G
hepatic parenchyma transection, 93 Glissonean pedicle approach, 61
mobilization, 93
patient’s position, 93
specimen retrieval, 93 H
trocar arrangement, 93 Hepatocellular carcinoma (HCC), 5, 27
complications, 94 Hilar access approach, 6, 61
contraindications, 90
indications, 90
of Spiegel lobe I
hemostasis, 93 Indocyanine green clearance (IGG) excretion
isthmus transection, 90 test, 27
mobilization, 90
patient position, 90
specimen retrieval, 93 L
trocars arrangement, 90 Laparoscopic anatomical hepatectomy (LAH)
Child Turcotte Pugh (CTP) score, 27 advantages, 3, 5
Child-Pugh classification, 35 anterior part transection, 12, 13
Colorectal liver metastasis (CRLM), 5 bleeding, 11
CTP score. See Child Turcotte Pugh (CTP) Couinaud segments, 2, 4, 5, 14
score extrahepatic Glissonean pedicle
Cysts fenestration approach, 6, 7, 9
advantages, 29 Fissural approach, 9
atresia, 32 hepatic veins exposure, 14
complications, 32 Hilar access approach, 6
contraindications, 30 intrahepatic Glissonean pedicle
deroofing, 30 approach, 6, 9
drainage, 32 intraoperative navigation, 14–17

https://doi.org/10.1007/978-94-017-9735-1
106 Index
Laparoscopic anatomical hepatectomy right lobe mobilization, 79

(LAH) (cont.) specimen retrieval, 81–84
laparoscopic intraoperative trocar arrangement, 78
ultrasonography, 3 ultrasonic dissector, 83
laparoscopic limited anatomical Lapro-Clip™ absorbable clip, 82
resection, 3 Left hemihepatectomy, 22, 23
main vessel control approaches Left hepatectomy
classification, 7 absorbable chip, 60, 64
middle part transection, 12, 14 complications, 66
oncological value, 5 contraindications, 60
parenchyma dissection, 5, 12 drainage, 60, 65, 66
patient position, 3 first hilum dissection, 61
posterior part transection, 12, 13 hemostasis, 60, 64, 65
postoperative abdominal adhesions, 5 indications, 59
routine examination, 14, 15 left liver artery dissection, 60, 61
technique characteristics, 3 left portal pedicles transection, 60, 62
trans-thoracic LAH, 3 left portal vein dissection, 60, 61
trocar distribution, 3 LHV transection, 60, 64, 65
vessel control approaches classification, 6 liver surface, ischemic line, 60, 63
Laparoscopic left lateral sectionectomy parenchymal dissection, 62
(LLLS) patient position, 60
advantages, 51 perihepatic ligaments mobilization
benign tumor specimen withdrawal, 58 order, 60
complications, 58 RHV exposure, 60, 63
contraindications, 52 right coronary ligament incision, 60
deep parenchyma dissection, 55, 56, 58 second hilum dissection, 62
errhysis, argon beam, 56, 57 specimen withdrawal, 65
four-trocar method, 52 superficial parenchyma dissection, 60, 63
giant hemangioma exploration, 52 trocar distribution, 60
hepatocellular carcinoma Left hepatic vein (LHV) transection, 56, 57
exploration, 52, 53 Left lateral decubitus position, 20, 21
indications, 51 Left lateral lobectomy, 22
lateral liver section mobilization, 58 Lithotomy position, 19–21
left coronary ligament transection, 53 LLLS. See Laparoscopic left lateral
left deltoid ligament transection, 53, 54 sectionectomy (LLLS)
left hepatic vein transection, 55–57 LRH. See Laparoscopic right hepatectomy
omentum transection, 52–54 (LRH)
patient position, 52
portal pedicles dissection, 54, 55, 58
portal pedicles transection, 54, 55 O
postoperative drainage, 56, 57 Open liver resection (OLR), 1, 2
round ligament transection, 53
short-term prognosis, 51
Laparoscopic right hepatectomy (LRH) P
complications, 84 Partial hepatectomy
contraindications, 78 complications
hemostasis, 81 biliary fistula, 43
hepatic parenchyma transection, 80, 81 CO2 embolism, 43
indications, 78 intra-operative hemorrhage, 41, 42
inflow/outflow vessels control, 79, 80 contraindications, 36
laparoscopic ultrasonography, 79 drainage, 40
left lateral semi-decubitus position, 84 4-trocar technique, 36
patient’s position, 78 hemostasis, 40
resection, 2 indications, 35
Index 107
intra-operative ultrasonography, 39 tumor removal, 73, 76

laparoscopic exploration, 36 Reverse Trendelenburg position, 19, 20
large-scale partial hepatectomy, 39 RFA. See Radiofrequency ablation (RFA)
liver parenchyma dissection, 38 Right hemihepatectomy, 23, 24
operating points, 40, 41 Right posterior lobectomy, 23
patient position, 36 Right posterior sectionectomy, 2
pre-operative imaging data, 39 bile leak, 71
wedge resection, 36 bleeding, 71
Pneumoperitoneum complications, 71
side effect, 28 contraindications, 67
Veress needle, 22, 78 drainage, 71
Ports placement, 19 hemostasis, 70, 71
Preoperative evaluation indications, 67
general state and nutritional status, 25 inflow blood control, 70
imaging examination left vena cava ligament transection, 68, 69
CT scan, 26 patient position, 68
MRI, 26 right posterior portal pedicels
PET-CT, 26 transection, 70
ultrasonography, 25 right posterior section exploration, 68
systemic organ function evaluation specimen withdrawal, 71
cardiac function, 26 superficial parenchyma dissection, 69
liver function, 27 trocar distribution, 68
psychological expectations, 27
renal function, 27
respiratory function, 26 S
Single-site hepatectomy
advantages, 49
R disadvantages, 49
Radiofrequency ablation (RFA) by endoscopic linear staples, 47, 48
bleeding vessels, 97, 99 by harmonic scalpel, 47, 48
cirrhotic nodes, 100, 101 incisions, 49
for cirrhotic patients, 95 indications, 45
complications, 100–102 long-distance laparoscopic observation, 47
for deep tumors, 98 patient position, 45, 46
exclusion criteria, 96 surgeons position, 45, 46
hyper-enhanced lesion, 100, 102 transumbilical postoperative drainage, 47,
hypo-echoic lesion, 100, 102, 103 48
inclusion criteria, 96 Triport access, 47
inhomogeneous echoic lesion, 100, 101 5 mm trocars’ access, 47
laparoscopic ultrasonography, 96, 97
needle, 98, 100
post-operative biochemistry results, 103 T
regular liver resection, 103 Trocar positioning, 22–23
temperature, 103
ultrasonic dissector, 99
Retroperitoneal laparoscopic hepatectomy U
clinical practices, 73 Ultrasonography, 25
indications, 73, 74
patient position, 73–75
perirenal fat dissection, 73, 75 V
pneumoperitoneum pressure, 74 Veress needle, 22, 78
specimen, 73, 76

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Rong Liu

Theory and Techniques

ISBN 978-94-017-9734-4 ISBN 978-94-017-9735-1 (eBook)

Library of Congress Control Number: 2017953440

© Springer Science+Business Media B.V. 2017

Printed on acid-free paper

This Springer imprint is published by Springer Nature

Since the first laparoscopic cholecystectomy was performed in 1987, almost 30

Beijing, China Rong Liu

1 Laparoscopic Anatomical Hepatectomy. . . . . . . . . . . . . . . . . . . . . . . . . 1

4.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

8 Laparoscopic Left Hepatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

11 Laparoscopic Right Hepatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

© Springer Science+Business Media B.V. 2017 1

Fig. 1.1 The dramatically increased number of literatures about LLR

1.1 What is LAH?

Laparoscopic anatomical hepatectomy (LAH), instead of laparoscopic regular hep-

Fig. 1.2 The scheme of

1.2 Why Choose LAH?

The role of LAH is built on its surgical and oncological values.

1.3 Key Issues and Technique Details

1.3.1 Identification of Portal Pedicles and Root of Hepatic Vein

Portal pedicies Root of Hepatic Vein

Intra-fascial Extra-fascial Intrahepatic Extrahepatic

Hilar access Glissonean pedicle Fissural

Fig. 1.3 Classification of main vessel control approaches of LAH

Fig. 1.4 Variations of extrahepatic arteries

Fig. 1.5 Variations of extrahepatic portal veins

Fig. 1.6 Fissural approach

1.3.2 Prevention of Bleeding and Hemostasis

Fig. 1.9 Ligation of left

1.3.3 Parenchymal Dissection and Exposure of Hepatic Vein

Fig. 1.10 Three parts of

Fig. 1.11 Transection of

Fig. 1.12 Transection of

Fig. 1.13 Transection of

1.3.4 Intraoperative Navigation

or dyeing. In recent researches, the fluorescein staining technique and augmented

Fig. 1.15 The four

With the help of laparoscopic intraoperative ultrasonography and TPQSI, the

2.1 Patient Position

2.1.1 The First Position: Reverse Trendelenburg Position

The patient is placed in supine position with a 20-degree reverse-Trendelenburg

2.1.2 The Second Position: Lithotomy Position

© Springer Science+Business Media B.V. 2017 19

Monitor Surgeon Assistant

Assistant Instrument nurse

Fig. 2.1 Operating room setup of reverse Trendelenburg position

Fig. 2.2 The side view of lithotomy position

2.1.3 The Third Position: Left Lateral Decubitus Position

Fig. 2.3 The front view of lithotomy position

Fig. 2.4 The side view of left lateral decubitus position

2.2 Principle of Trocar Positioning

2.2.1 Left Lateral Lobectomy and Left Hemihepatectomy

Fig. 2.6 Port position for

2.2.2 Right Posterior Lobectomy

2.2.3 Right Hemihepatectomy

Fig. 2.7 Port position for

It is very important to do adequate preparation before surgery for laparoscopic liver

3.1 Preoperative Evaluation of Patients

Beijing, China Rong Liu

1 Laparoscopic Anatomical Hepatectomy. . . . . . . . . . . . . . . . . . . . . . . . . 1

4.4 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

8 Laparoscopic Left Hepatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

11 Laparoscopic Right Hepatectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

1.1 What is LAH?

1.2 Why Choose LAH?

1.3 Key Issues and Technique Details

1.3.1 Identification of Portal Pedicles and Root of Hepatic Vein

1.3.2 Prevention of Bleeding and Hemostasis

1.3.3 Parenchymal Dissection and Exposure of Hepatic Vein

1.3.4 Intraoperative Navigation

2.1.1 The First Position: Reverse Trendelenburg Position

2.1.2 The Second Position: Lithotomy Position

2.1.3 The Third Position: Left Lateral Decubitus Position

2.2 Principle of Trocar Positioning

2.2.1 Left Lateral Lobectomy and Left Hemihepatectomy

2.2.2 Right Posterior Lobectomy

2.2.3 Right Hemihepatectomy

3.1 Preoperative Evaluation of Patients

3.1.1 Imaging Examination

3.1.2 Systemic Organ Function Evaluation

3.1.2.1 Cardiac Function

3.1.2.2 Respiratory Function

3.1.2.3 Renal Function

3.1.2.4 Liver Function

3.1.2.5 Patients with Psychological Expectations

3.2 Anesthesia in Laparoscopic Liver Resection

4.1 Indications and Contraindications

5.1 Indications and Contraindications

5.2.1 Patient’s Position and Trocar Placement

5.2.2 Laparoscopic Exploration

5.2.3 Partial Hepatectomy

5.2.4 Hemostasis and Drainage

5.3 Major Operating Points

5.4.1 Intra-Operative Hemorrhage

5.4.2 CO2 Embolism

5.4.3 Biliary Fistula

6.2 Steps and Key Techniques

7.1 Indications and Contraindications

7.2.1 Patient Position and Trocar Distribution

7.2.2 Exploration and Mobilization

7.2.3 Rough Dissection of the Portal Pedicles of Segments 2 and 3

7.2.4 Transection of the Portal Pedicles of Segments 2 and 3

7.2.5 Dissection of the Deep Parenchyma to Expose LHV

7.2.6 Transection of the Left Hepatic Vein