Needle-Assisted Single-incision Laparoscopic (naslap) Liver Surgery

Minoru Tanabe, MD PhD, Shigeyuki Kawachi, MD PhD, Osamu Itano, MD PhD, Masahiro Shinoda, MD PhD, Minoru Kitago, MD PhD, Norihito Wada, MD PhD, Yuko Kitagawa, MD PhD. Department of Surgery, Keio University School of Medicine

 INTRODUCTION: Single–incision laparoscopic surgery is becoming more common for a multitude of laparoscopic procedures. However, there are few reports about liver surgery so far. In this session, we present our initial experience of needle-assisted single-incision laparoscopic (NASLAP) liver surgery. The concept of this method is to assist single-incision laparoscopic surgery by using needle devices such as RFA/microwave coagulator and/or our original needle devices. We developed two types of novel needle device; one is for retracting organs, which is assembled inside the abdominal cavity, and the other is for water dripping for bipolar coagulation.
METHODS: A intraumbilical vertical 2.5cm- incision was made and the SILS port (Covidien, Norwalk, CT, USA) was introduced into the abdomen. One 12mm and two 5 mm trocars were put through the port and the pneumoperitoneum was induced at 8 mmHg. A 5mm flexible fiberscope was used in all operations. <NASLAP hepatectomy> The transection plane was precoagulated using a flexible microwave probe or bipolar coagulation device for laparoscopic surgery. Parenchymal transection was accomplished with the ultrasonic coagulating shears and the ultrasonic aspirator. The original needle retractors inserted through the upper abdominal wall were used to control the direction of transection. This needle device is assembled inside the abdominal cavity. Water dripping needle was also inserted through upper abdominal wall, in order to moisturize cutting surface of the liver when bipolar coagulation is used for hemostasis. The indication of NASLAP hepatectomy includes the tumors in the lower peripheral part of the right anterior, and left medial/lateral segments of the liver. <NASLAP ablation therapy> A laparoscopic ultrasonography probe and a forceps as a retractor were introduced into the abdomen through the SILS port. The Ablation needle (radiofrequency or microwave energy device) was inserted through the best point of the abdominal wall according to the location of the tumor. The indication of NASLAP ablation therapy includes the tumors adjacent to gastrointestinal tract, because heat injury can be avoided by retracting gastrointestinal tract by this operation. In addition, another candidate for this operation is the tumors undetectable by preoperative extracorporeal ultrasonography, because clearer image of the tumors can be obtained by laparoscopic ultrasonography.
RESULTS: From April 2009 to September 2011, there were 9 limited hepatectomy and 6 ablation therapy were carried out at our hospital using NASLAP technique. There were no conversion and no intraoperative complications. The postoperative courses of all patients were uneventful.
CONCLUSION: Needle devices expand the possibility of single-incision laparoscopic liver surgery. NASLAP procedure for liver tumors is feasible and safe for highly selected patients.

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