En-bloc stapling transection of Glissonian pedicles and LHV for Laparoscopic left lateral sectionectomy

Takashi Kaizu, MD, Yusuke Kumamoto, MD, Hiroshi Tajima, MD, Ryo Nishiyama, MD, Hiroshi Kawamata, MD, Masahiko Watanabe, MD. Department of Surgery, Kitasato University School of Medicine

INTRODUCTION: Laparoscopic left lateral sectionectomy (LLLS) is one of the widely accepted procedures for laparoscopic liver resection (LLR). In general, LLLS requires two-step stapling transection. One is for Glissonian pedicles to Segment II/III, the other is for left hepatic vein (LHV).  Here, we report the new technique of en-bloc stapling, transect both Glissonian pedicles and LHV simultaneously.

METHODS: Between December 2002 and September 2015, 193 LLR were performed and 38 LLLS (20% of 193 LLR) were included in this retrospective study. Among the 38 LLLS, we applied two-step stapling technique in 35 cases (two-step group) and en bloc stapling technique in recent 3 cases (en-bloc group), and evaluated surgical outcomes.

SURGICAL TECHNIQUE: The falciform and left triangular ligament was divided using a harmonic scalpel.  After liver parenchymal transection using CUSA Exel, Segment II/III pedicles were stapled and divided using Echelon FlexTM 60 Blue cartridge.  Residual parenchyma including LHV was stapled and divided using Echelon FlexTM 60 White cartridge.  In the en-bloc stapling technique, both Glissonian pedicles and LHV were stapled and divided simultaneously using Echelon FlexTM 60 Blue cartridge.  The cotton tape was used for countertraction of Segment II/III, which prevent liver tissue extrusion and slippage during stapler closure.

RESULTS: There was no significant difference in surgical outcomes between two-step group and en-bloc group as follows; the median operative time, intraoperative blood loss, and postoperative hospital stay were 220 versus 315 minutes (two-step group versus en-bloc group, P = 0.18), 100 versus 100 ml (P = 0.15), and 9 versus 7 days (P = 0.06), respectively.  In two-step group, there were 3 (9%) conversions to laparotomy and 4 (11%) postoperative complications.  No complication and open conversion occurred in en-bloc group.  There was no mortality in both groups.

CONCLUSIONS: Sufficient exposure of the glissonian pedicles and LHV for safety stapler positioning may require longer operative time in en-bloc group. LLLS using en-bloc stapling transection is simple, safe and feasible technique with acceptable morbidity.


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