Laparoscopic Anatomical Combined Segment 3 and Segment 4 Liver Resection

Han Lim Choi, Ho-Seong Han, Yoo-Seok Yoon, Jai Young Cho, YoungRok Choi. Seoul National Univ. Bundang Hospital

Background: The extent of liver resection is best tailored to the patient’s status, and performing anatomical liver resection while preserving the liver volume as much as possible is the optimal strategy. This video shows the technical methods used for a laparoscopic anatomical segmentectomy of combined segment 3 (S3) and segment 4 (S4).

Patient and methods: A 63-year-old woman underwent a laparoscopic left hemicolectomy for cancer of the descending colon. Three years after surgery, follow-up abdominal computed tomography revealed a 2.1 cm solid mass in S4 with invasion to the S3 Glisson pedicle. The possible preoperative diagnoses were hepatocellular carcinoma, cholangiocarcinoma, and liver metastasis. The patient had viral hepatitis C and her liver function was graded Child–Pugh class A. Laparoscopic anatomical combined S3 and S4 liver resection was planned to preserve the remnant liver volume. The resection was performed with a selective Glissonian pedicle approach.

Results: The operation took about 290 min and the estimated intraoperative blood loss was approximately 400 ml. No intraoperative transfusion was necessary. The final pathology confirmed a cholangiocarcinoma, with a safe resection margin. On postoperative day 5, the patient recovered with no problems, and postoperative CT scan showed no evidence of any complications.

Conclusion: Laparoscopic anatomical combined S3 and S4 liver resection is a feasible operative procedure in patients with a risk of hepatic insufficiency after left hemi-hepatectomy because of limited liver function, and can be better performed in expert centers.