Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy

With this minimally invasive method obtaining a wide range of negative margins is easier and avoids the spread of tumor tissue. This method helps in maximizing R0 resection, and avoiding perioperative complications. This technique can be used in laparoscopic hepatic resection surgeries involving resection of four to five segments.

Because this minimally invasive surgical method requires experience in open surgeries, appropriate open surgery training is recommended. After preparing the patient for the procedure, pull the fundus of the gallbladder upward, and use a harmonic scalpel for Calot's Triangle Dissociation. Take care to ligate the cystic duct and artery with medium-sized hemostatic clips.

Avoid cutting the gallbladder and leave the gallbladder in situ primarily. Carefully separate the left coronary and triangular ligaments, avoiding injury to the adjacent phrenic vein branches. Then prepare for hepatic inflow occlusion by accessing from left to right behind the hepatoduodenal ligament through a sling removed from the attached 14F single human catheter.

After ligating the left hepatic artery with medium-sized vascular clips ensure that the first porta hepatis has been blocked with the single lumen catheter to prevent unexpected bleeding during the mobilization of the left hepatic pedicle. Gently lift the inferior edge of the liver free the left glissonean pedicles by the Laennec membrane and hilar plate gap, and then prepare a tourniquet system to block the left hepatic inflow by inserting an 8F single human catheter through the left glissonean pedicle. After releasing the first porta hepatis, block the left hepatic pedicle by clamping the single lumen catheter with a hemostatic clip which will be stapled after parenchyma transection.

Follow the dividing line to seek and mark the projection positions of the middle hepatic veins with laparoscopic ultrasonography. Pay attention to mapping the location and trajectories of the vital intrahepatic vessel, especially those on the expected transverse plane of the liver parenchyma. Drag the gallbladder's fundus using an ultrasonic scalpel with an assistant's help, and transect the parenchyma from the foot to the head side along the middle hepatic vein.

Trigger the ultrasonic scalpel early to reduce hepatic parenchymal bleeding effectively, and do not clamp the scalpel tip to avoid vessel damage. Secure the large intrahepatic vessels and bile ducts found during the parenchymal resection with 2-O sutures if necessary. Now, expose the vascular pedicles inflowing into segments 4A, 4B, and the left hepatic vein in the cutting line.

Then expose the whole middle hepatic vein, and its tributaries fully, and dissect the roots of the left and middle hepatic vein later. Use monopolar electrocoagulation for hemostasis when bleeding spots are found on the cut surface. Wrap the resected left hepatic lobe in a plastic bag.

Take it out through a four centimeter long incision in the lower abdomen, and place two drainage tubes. The resected liver tissue specimen with an attached gall bladder is shown. The paraffin pathology of the tumor confirmed hepatocellular carcinoma which was 2.2 centimeters from the negative liver resection margin.

No abnormal heterogeneous enhancement was observed in the remaining liver parenchyma after six days and one month post-surgery. It is important to avoid cutting the gallbladder, and leaving the gallbladder in suture primarily. Also free the left Glissonean pedicles by the gap between the Laennec membrane and the hilar plate.

This method can also be used for hepatic portal blockade with sutures blocking the hilar of the liver. However, the blocking time is difficult to control.