Laparoscopic Left Hemihepatectomy Combined with Caudate Lobe Resection

The scope of our research is the application of laparoscopic anatomic hepatectomy to treat intrahepatic cholangiocarcinoma. We demonstrated the surgical laproscopic resection of anatomic caudate lobe tumors is feasible. The challenge of this radical surgery arise along its unique anatomical location, such as its deep penetration into the liver parenchymas and its proximity to major vessels and so on.

Our studies show one successful laparoscopic radical hepatectomy for caudate lobe tumor by video, and more and more similar laparoscopic surgeries are being performed. This will further put more laproscopic anatomic hepatectomy for the treatment of liver tumors, even in special location. For preoperative planning, obtain axial views of the patient's CT scan during the venous phase.

To begin, administer 1 g of ceftriaxone sodium to the patient through an elbow intravenous injection 30 minutes before the skin incision to prevent infection. Perform tracheal intubation under general anesthesia. Puncture and catheterize the right radial artery using a 20-gauge catheter and the internal jugular vein using an 8 French catheter under ultrasound guidance.

After preparing the surgical area, make a 10 mm longitudinal skin incision below the umbilicus. Insert a disposable pneumoperitoneum needle through the incision and inject carbon dioxide after connecting the needle to the pneumoperitoneum machine to establish pneumoperitoneum. Next, insert a 10 mm iron trocar into the incision.

Position the patient supine with legs apart, head raised 30 degrees, and feet lowered after confirming no puncture damage. Place two 12 mm trocars on the right and left midclavicular line four finger widths above the umbilicus. Insert two 5 mm trocars into the right anterior axillary line subcostal area, and left midclavicular line subcostal area.

Perform laparoscopic abdominal exploration. Check for abdominal injuries, puncture bleeding, and significant extra hepatic metastases to assess the feasibility of radical surgery. Now free the left half of the liver and divide the round and falciform ligaments back to the hepatic vein fossa.

Divide the left triangular and left coronary ligaments until the lateral border of the left hepatic vein is identified. Then clamp the proximal round ligament of the liver. Expose the hepatoduodenal ligament after accessing the lesser omentum.

Routinely position a hepatic blood flow occlusion band and if necessary, use the Pringle method for intermittent hepatic blood flow blockage. For the dissection phase after lifting the left lateral lobe, fully open the lesser omentum to expose the caudate lobe. Using a non-traumatic grasper and a 10 mm right angled dissecting forceps, identify, sling, and dissect the left hepatic pedicle.

After a few minutes, create a marked preresection line with electrocautery along the ischemia line between the left and right halves of the liver. Then use an ultrasonic knife to incise the liver tissue along the marked line, starting from the front of the upper liver surface and progressing backward until the left and right hepatic pedicles are fully exposed. Now, fix pipes larger than 4 mm in diameter with clips and dissociate them at the distal end using an ultrasonic knife.

Dissect the space between the caudate lobe and the inferior vena cava through a dorsal approach. Clamp the short hepatic vein with a Hem-o-lok and disconnect it at the distal end. After fully exposing the inferior vena cava, mark the right pericaval plane, which represents the imaginary right margin of the caudate lobe.

Then remove the suspension line from the left hepatic pedicle and disconnect the left hepatic pedicle using linear cutter reloads. Dissect the hepatic pedicle of the caudate lobe along the broken end of the left hepatic pedicle. Clamp the proximal end with two Hem-o-loks and cut the distal end using an ultrasonic knife through the left side approach.

Pull the first hepatic portal to the right to expose the right pericaval plane. Cut the liver parenchyma along the right margin of the caudate lobe until the common trunk of the middle hepatic vein and left hepatic vein is revealed. Next, clamp the caudate vein with a Hem-o-lok and disconnect it at the distal end.

Complete the transection of the common trunk of the hepatic veins using linear cutter reloads, fully separating the left liver and caudate lobe. Now, perform thorough hemostasis of the surgical wound. Place the resected specimen in a bag and remove it through a 6 cm vertical incision near the navel in the lower abdomen.

Insert two drainage tubes:one on the liver section, and another in the hepatorenal recess. The total caudate lobe and left liver were successfully removed in 200 minutes with minimal intraoperative blood loss of 50 ml. The surgery required approximately 1, 500 ml of fluid replacement with no need for blood transfusion.

The patient exhibited stable intraoperative conditions with a urinary output of 150 ml.