Laparoscopic Left Hemihepatectomy Combined with Caudate Lobe Resection

Summary

Intrahepatic cholangiocarcinoma of the caudate lobe is a challenge for many surgeons due to its unique location. Here, we present a protocol to show the step-by-step details of laparoscopic left hemihepatectomy combined with caudate lobe resection for cholangiocarcinoma.

Abstract

Intrahepatic cholangiocarcinoma (ICC) is the common malignant tumor of the liver. Radical surgical resection is the mainstay of potentially curative treatment for ICC. Anatomical liver resection for ICC in the caudate lobe is one of the most difficult liver resections. Because the tumor is located deep and easily invades surrounding blood vessels, such as the left hepatic pedicle, right hepatic pedicle, and middle hepatic vein. Laparoscopic anatomic hepatectomy of the caudate lobe not only ensures a negative incision margin but also offers a more minimally invasive approach for patients. This technique is poised to become the preferred choice for radical surgery of the caudate lobe in the future. In this surgical protocol, a 65-year-old male patient with intrahepatic cholangiocarcinoma (sized about 3.2 × 1.9 cm²) located in the left caudal lobe underwent laparoscopic left hemihepatectomy combined with caudate lobe resection successfully without any postoperative complications. Postoperative pathological examination showed a cholangiocarcinoma with a tumor thrombus visible in the vasculature. The patient was discharged on the 14th postoperative day. Laparoscopic left hemihepatectomy combined with caudate lobectomy for the treatment of caudate lobe ICC can be performed safely and does not add significantly to the morbidity or mortality of the procedure.

Introduction

Intrahepatic cholangiocarcinoma originates from intrahepatic bile duct epithelial cells and is a cholangiocarcinoma occurring above the secondary bile duct of the liver. The incidence of ICC is second only to that of hepatocellular carcinoma (HCC), accounting for 10% to 15% of primary liver cancer and about 20% of bile duct cancer¹. The incidence of ICC has been increasing year by year in the world, increasing by 140% in the past 40 years². Surgical resection remains the mainstay of potentially curative treatment for ICC. However, only 20% to 30% of patients have the possibility of surgical resection. After surgical resection, the 5-year overall survival rate of ICC patients is only 20% to 35%³. This is because even if radical resection is performed, only a few patients can obtain negative margins⁴. It is particularly important for early ICC patients to obtain curative surgery. The curative surgery for ICC patients is closely related to surgical margins. Two recent meta-analyses^5,6 indicated that a surgical margin width of >1 cm is associated with better overall survival. A study⁷ involving 126 patients showed that a margin ≥1.0 cm was associated with better overall survival (OS) and recurrence-free survival (RFS).

In ICC surgery, anatomical liver resection, which is important for the prognosis of ICC patients⁸, not only can obtain a safe surgical margin but also can excise the violated liver pedicle. A study⁹ reported that the most common infiltrating pathway for caudate lobe cholangiocarcinoma is through fibrous connective tissue along the Glisson system, not the bile duct. In a prior study, Si et al.¹⁰ reviewed data from 702 ICC patients and found that the incidence of complications was similar between anatomical resection and non-anatomical resection, and anatomical resection was associated with better disease-free survival and overall survival at 1, 3, and 5 years. Another propensity matching study¹¹ about ICC identified nonanatomical resection as an independent risk factor for OS (p < 0.05).

However, surgical resection of the caudate ICC can be challenging for the surgeon. It is very difficult for surgeons to explore the caudate lobe because of its unique anatomical location, such as its deep penetration into the liver parenchyma and its proximity to major vessels¹² (the inferior vena cava, middle or right hepatic veins, portal vein, and ligamentum venosum). These can make it difficult to obtain a broad field of view during surgery and get an invisible cutting edge. In recent years, with the detailed study of liver anatomy, the rapid development of laparoscopic technology, and the continuous promotion of the concept of precise liver resection, ICC surgical management has grown from isolated caudate lobectomy^13,14 to laparoscopic hemihepatectomy combined with caudate lobectomy¹⁵, which is rarely reported in the literature. There is a great need for videos of successful operations to guide the widespread use of such operations in the future. Here, we present a laparoscopic left hemihepatectomy combined with caudate lobe resection to treat an intrahepatic cholangiocarcinoma in the caudate lobe.

A 65-year-old Chinese man was admitted to the hospital with an incidentally detected hepatic mass by abdominal ultrasonography. Physical examination showed no significant abnormalities. Laboratory examinations, including routine blood testing, liver function tests, coagulation, and tumor indicators (AFP, CEA, CA199), were normal. Enhanced computed tomography (CT) of the upper abdomen showed a 3.2 1.9 cm² abnormal enhancement shadow at the S1/4/8 junction and showed that the middle hepatic vein (MHV) and left hepatic vein (LHV) shared a common trunk (Figure 1A). Enhanced magnetic resonance imaging (MRI) of the upper abdomen also revealed a 2.5 2.0 cm² nodule in the same area, but suggesting ICC (Figure 1B). After completing the preoperative evaluation, we decided to perform a laparoscopic left hemihepatectomy combined with caudate lobe resection to ensure a negative surgical margin.

Protocol

This protocol follows the guidelines of the human research ethics committee of Meizhou People's Hospital. Informed consent was obtained from the patients to release information and data related to this treatment.

1. Preoperative preparation

1. Prohibit the patient from eating for 6 h and drinking for 2 h before the operation.
2. Apply the antibiotic (1 g of Ceftriaxone sodium) through an elbow intravenous injection to prevent infection preventively 30 min before cutting through the skin.
3. Use tracheal intubation under general anesthesia. Puncture and catheterize the right radial artery (catheter size, 20 G) and the internal jugular vein (catheter size, 8 Fr) under ultrasound guidance.
4. Sterilize the skin with 0.5% iodine-based scrub and sterile towel sheets to fully expose the surgical area. Disinfect the surgical area with iodophor three times.

2. Surgical technique

1. Operation setting
   1. Cut the skin about 10 mm longitudinally below the umbilicus, then insert a disposable pneumoperitoneum needle through the incision. Inject CO₂ after the pneumoperitoneum needle is connected to the pneumoperitoneum machine to establish the pneumoperitoneum.
   2. Then, insert a 10 mm iron trocar into the incision. Change the patient from a supine position to a supine position with legs apart, head raised 30°, and feet lowered after examining no puncture damage.
      NOTE: The pneumoperitoneum pressure was set to 12 mmHg.
   3. Place two 12 mm trocars to the right and left midclavicular line above the umbilical 4 fingers (B and C), two 5 mm trocars to right anterior axillary line subcostal and left midclavicular line subcostal (D and E), see Figure 2.
   4. Perform abdominal exploration laparoscopically. Check for abdominal injury and puncture bleeding; check for the presence of significant extrahepatic metastases to evaluate the feasibility of radical surgery.
2. Exploration phase
   1. Free the left half of the liver and divide the round and falciform ligaments back to the level of the hepatic vein fossa. Divide the left triangular ligament and the left coronary ligament, extending until the lateral border of the left hepatic vein is identified.
   2. Clamp the proximal round ligament of the liver.
   3. Reveal the hepatoduodenal ligament upon accessing the lesser omentum and routinely position a hepatic blood flow occlusion band. If necessary, utilize the Pringle method to intermittently block hepatic blood flow.
3. Dissection phase
   1. Dissect the left hepatic pedicle using the extrathecal approach.
      1. After lifting the left lateral lobe, expose the caudate lobe by fully opening it to the lesser omentum. Identify, sling, and dissect the left hepatic pedicle using a nontraumatic grasper and a 10 mm right angle dissecting forceps.
      2. A few minutes later, create a marked pre-resection line with an electrocautery based on the ischemia line of the left and right halves of the liver (Figure 3A, B).
   2. Use an ultrasonic knife to incise the liver tissue, starting on the upper liver surface from the front to the back, until the level of the left and right hepatic pedicle is fully exposed along the marked line (Figure 3C).
   3. Fix the pipe structured >4 mm in diameter with clips and dissociate it with an ultrasonic knife at the distal end.
   4. Utilizing the time to activate the liver, dissect the space between the caudate lobe and the inferior vena cava (IVC) through a dorsal approach. When encountering the short hepatic vein (VHS), clamp it with a hem-o-lok and then disconnect it at the distal end.
   5. After fully exposing IVC, mark the right paracaval plane, which is the imaginary right margin of the caudate lobe (Figure 3D).
   6. After removing the suspension line of the left hepatic pedicle, disconnect the left hepatic pedicle by linear cutler reloads (Figure 4A).
   7. Along the broken end of the left hepatic pedicle, look for the hepatic pedicle of the caudate lobe and dissect it, then clamp its proximal end with two hem-o-loks and cut its distal end with an ultrasonic knife through the left-side approach (Figure 4B).
   8. Pull the first hepatic portal towards the right to expose the right paracaval plane. Along the right margin of the caudate lobe, as marked, cut off the liver parenchyma beneath the junction of the left and right liver pedicles until the common trunk of MHV and left hepatic vein (LHV) was revealed (Figure 4C).
   9. When encountering the caudate vein, clamp it with hem-o-lok and disconnect at its distal end.
   10. Subsequently, complete the transection of the common trunk of MHV and LHV by using linear cutler reloads to completely separate the left liver and caudate lobe, taking care to avoid traction injury to the middle hepatic vein and the vena cava.
   11. After thorough hemostasis of the wound, place the specimen in a bag and remove it through a 6 cm vertical incision around the navel in the lower abdomen. Place two drainage tubes on the liver section and the hepatorenal recess, respectively.

Results

The relevant outcome of this operation is shown in Table 1. The patient's total caudate lobe and left liver were removed in 200 min with 50 mL of blood loss and about 1500 mL of fluid replacement. The intraoperative urinary output was 150 mL. The time of transecting the liver parenchyma, including dissecting the hepatic pedicle and the space between the caudate lobe of the liver and the inferior vena cava, was 84 min. The pringle maneuver was performed three times (the time of hepatic hilar occlusion was...

Discussion

The caudate lobe ICC often invades surrounding liver segments or adjacent liver pedicle, which treatment principle is similar to some hilar cholangiocarcinoma¹⁷, and due to its anatomical location and biological characteristics, the caudate lobe ICC is prone to damage surrounding structures during surgery, leading to massive bleeding and postoperative bile leakage. So, laparoscopic caudate lobectomy is one of the most difficult liver resections, which needs high skill and experience. We reported a...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Bipolar radiofrequency excision hemostatic device	ERBE	20195-136
Disposable trocar	Kangji Medical	101Y.611
Endoscopic linear cutter reloads	Ethicon, LLC	ECR60W
Laparoscopic system	STORZ	26003BA
Laparoscopic system	STORZ	TC200
Non-absorbable polymer ligation clips (Hem-o-lok)	Teleflex Medical	544240
Pneumoperitoneum needle	Kangji Medical	101Y.611
Ultrasound knife	Johnson	GEN11
Video system	SONY	LMD-3252SC