Atypical Laparoscopic Right Anterieur Bisegmentectomy for Single Tumor

Ludmil M Veltchev, MD PhD, Manol A Kalniev, MD PhD. Department of Abdominal surgery


Anterior right sectorial resection or bisegmentectomy 5-8 is an indication for primary malign liver tumors or single metastasis. Anatomical disposition of this sector between hilar portal arterial inflow and venous outflow is making its resection very difficult without the sacrifice of the intact blood flow to right posterior segments. Gold standard procedure is wedge liver resection under intraoperative ultrasound and blood control by clamping of the right hepatic artery.
Introduction of laparoscopic manipulations on the liver permits performance of typical major liver resections under Pringle maneuver and in selected cases hilar plate dissection and blood control proximally to divergence of hepatic artery. It is difficult in this antegrad methodology to find exact borders between right anterior sector and right posterior sector.
Our method for save laparoscopic bisegmentoctomy 5-8 includes the following steps:
1. Pneumoperitoine
2. 30º camera insertion
3. Laparoscopic cholecystectomy
4. The hepatoduodenale ligament dissection and insertion of elastic tape for Pringle maneuver, exteriorized by 5 mm hard tube for security.
5. Determination of the place for minimal liver dissection of the gall bladder bed to find and clipping of the right anterior artery branch. Avascularization of the anterior sector. We found the right anterior branch at the point where projection of right hepatic artery crosses the sagital line of the gallbladder bed and 1.5-2 cm superior-posterior intrahepataly.
6. Wedge resection of unvascularized area of segments 5-8 using bipolar instrument and clips.
7. Minilaparotomy for evacuation of specimen.
–   No rick for blood lost
–   Absolutely demarcation of resection lines
–   No rick for damage of right and middle hepatic veins if follow demarcation.
–   Difficult to find right anterior branch using gallbladder bed: need to follow the right hepatic artery from  liver hilar just to division to anterior and posterior branch and clipping. It my have parenchymal phase.

Session Number: Poster – Poster Presentations
Program Number: P398
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