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.