Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Guifang Zeng; Jiafan Chen; Wenfeng Zhuo; Baojia Zou; Peiping Li; En Lin; Decheng Li; Chaonong Cai; Jian Li

doi:10.3791/63555

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Method Article

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

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DOI:

10.3791/63555

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June 16th, 2023

Guifang Zeng^*¹ , Jiafan Chen^*¹ , Wenfeng Zhuo^*¹ , Baojia Zou¹ , Peiping Li¹ , En Lin¹ , Decheng Li¹ , Chaonong Cai¹ , Jian Li¹

¹Department of Hepatobiliary Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University

^* These authors contributed equally

Summary

Here, we present a protocol to perform a modified laparoscopic anatomic hepatectomy using improved techniques and instruments.

Abstract

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to the anatomical characteristics of the liver, with intraoperative hemorrhage being a primary concern. Intraoperative blood loss is the leading cause of conversion to open surgery; therefore, effective management of bleeding and hemostasis is crucial for a successful LAH.

The two-surgeon technique is proposed as an alternative to the traditional single-surgeon approach, with potential benefits in reducing intraoperative bleeding during laparoscopic hepatectomy. However, there remains a lack of evidence to determine which mode of the two-surgeon technique yields superior patient outcomes. Besides, to our knowledge, the LAH technique, which involves the use of a cavitron ultrasonic surgical aspirator (CUSA) by the primary surgeon while an ultrasonic dissector by the second surgeon, has been rarely reported before.

Herein, we present a modified, two-surgeon LAH technique, wherein one surgeon employs a CUSA while the other uses an ultrasonic dissector. This technique is combined with a simple extracorporeal Pringle maneuver and low central venous pressure (CVP) approach. In this modified technique, the primary and secondary surgeons utilize a laparoscopic CUSA and an ultrasonic dissectorconcurrently to achieve precise and expeditious hepatectomy. A simple extracorporeal Pringle maneuver, combined with the maintenance of low CVP, is employed to regulate the hepatic inflow and outflow in order to minimize intraoperative bleeding. This approach facilitates the attainment of a dry and clean operative field, which allows for the precise ligation and dissection of blood vessels and bile ducts. The modified LAH procedure is simpler and safer due to its effective control over bleeding as well as the seamless transition between the roles of primary and secondary surgeons. It holds great promise for future clinical applications.

Introduction

The safety of hepatectomy has significantly improved in recent decades¹, and with the rapid advancements in diagnostic imaging, energy devices, and surgical techniques, laparoscopic hepatectomy has become a widely performed procedure that yields favorable clinical outcomes²^,³. Studies have demonstrated that anatomical hepatectomy yields superior outcomes compared to nonanatomic resection in patients with hepatocellular carcinoma⁴^,⁵. Consequently, laparoscopic anatomic hepatectomy (LAH) has gained popularity worldwide